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. The majority of children with the disease have their deformities corrected and their joints move normally without painful symptoms after treatment. If treatment is delayed, or even not treated, it can bring lifelong disability and physical and mental pain to the child. We hope to draw parents’ attention to timely diagnosis and treatment.
I. Etiology
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. Children with a family history are more likely to have recurrences than children without a family history.
(ii) Neuromuscular disease: It was found that there are abnormalities in the muscle fibers of the affected limb and that the fibroblasts contain contractile proteins, which is a factor leading to the recurrence of the deformity after correction of the deformity. There are also abnormalities in the nerves, and clinically we found that the affected children are often combined with lumbosacral laminectomy, and we also found that some children have poor toe movement and abnormal electromyography.
(iii) Vascular abnormalities
(iv) Developmental: Stagnation of the embryonic development process, abnormal fetal position, the presence of viral infection, injury and other factors are under study.
II. Pathology
1.Posterior aspect of the foot, contracture and tension of the medial ligament muscle, resulting in displacement or even dislocation of the foot bone.
2, the main deformities are foot inversion, inversion, ptosis, calf internal rotation 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 with poor stretchability, so tendon contracture often requires surgical treatment.
Third, the clinical manifestation
The deformity is gradually aggravated with age, and bursa and callus often appear on the lateral edge of the foot after standing and walking. Unilateral patients with calf muscle atrophy on the affected side become thin. Also pay attention to the whole body examination, skeletal muscle abnormalities of the limbs, spinal deformities and urinary system abnormalities, etc.
IV. Subtypes
1, postural clubfoot: may be caused by the late pregnancy in utero position, deformity of the 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.
V. Differential diagnosis.
Clubfoot generally has two major types of disease.
(A) stiffness
1, multiple joint contracture: after birth can be found in limb deformities, in addition to clubfoot, often involving the knee, upper extremity wrist and elbow joints, stiffness activity is limited. In severe cases, the shoulder and hip joints are also involved, and even hip dislocation.
2, cerebral palsy: for example, prematurity, cerebral hypoxia at birth, etc., advanced neuronal disease, performance limb muscle tone, some children can be seen in clonus, give stimulation joint tremors, hand and foot inflexibility. When the child falls asleep, the muscle tone decreases and the joint tremors disappear, and the foot becomes floppy. 3 Congenital clubfoot also belongs to this category.
(II) Softness
Common diseases are
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 all peripheral nerve damage muscle paralysis, muscle weakness, some patients incontinence.
VI. Treatment
The purpose of treatment is 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 the close cooperation of 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 a very small surgery) through manipulation massage, coupled with plaster or brace external fixation to correct 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.
(B) Surgical treatment
Generally, it 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.