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Nursing Care Plan | NCP Clubfoot

Clubfoot is a birth defect in which one or both of the baby’s feet are twisted at a sharp angle to the ankle so that the foot and lower leg resemble the head of a golf club. Clubfoot is usually an isolated congenital (present at birth) problem; it does not mean that the baby has a developmental disorder or defective internal organs.

Clubfoot is a congenital defect that varies in severity. Some babies have only one affected foot rather than both. About 50 percent of children have so-called flexible clubfoot, which can be corrected without surgery, while those with what doctors define as resistant clubfoot usually need surgery to correct the position of the foot. Resistant clubfoot is often associated with a thin calf and a small, high heel. Clubfoot does not affect a baby’s development until it is time for the infant to start walking. It is important to have the child evaluated for corrective treatment before he or she begins to walk, as children with clubfoot typically start walking on the outside of the foot. If only one foot is affected, the child will develop a limp. If both feet are affected, walking on the outside of the foot will produce a stiff and awkward-looking gait and weaken the muscles of the child’s calf.

Clubfoot is one of the most common congenital defects, occurring in one in 1,000 babies in the United States and most countries around the world. It is more common in Polynesia, however, occurring in about seventy-five children per 1,000. Between 30 and 50 percent of children with clubfoot are affected in both feet. Boys are twice as likely than girls to be born with clubfoot in the United States. The reason for the gender difference is not known. In terms of ethnic groups in the United States, the rate of clubfoot appears to be higher in Hispanic babies and lower in Asian American babies. As with the gender ratio, the reason for ethnic differences in the frequency of clubfoot is not known. Clubfoot is not clearly a genetic disorder in the strict sense but appears to run in some families. Parents of a child with clubfoot have a 10 percent chance of having a second child with the deformity. People with clubfoot have a 2 percent chance of having a first-degree relative (sibling, parent, or child) with clubfoot.

Nursing Care Plan Signs and Symptoms

The cause of clubfoot is not known. Various theories about the cause include the mother’s use of certain drugs (particularly MDMA or ecstasy, an illegal drug); compression of the child’s foot inside the mother’s uterus by a lack of amniotic fluid or by fibrous bands that form inside the amniotic sac; and one or more genetic abnormalities that have not yet been identified. Children with Edwards syndrome, a genetic disorder associated with an extra copy of chromosome 18, are often born with clubfoot or so-called rocker-bottom feet. Clubfoot is usually obvious at the time of the baby’s birth. The affected foot is usually turned outward with the heel turned inward; in some cases, the twisting of the foot may be so severe that it looks as if the foot is upside down. If only one foot is affected, it may be as much as half an inch (1.3 centimeters) shorter than the normal foot. In addition, the calf muscles on the affected leg are usually less developed than those on the normal leg. Clubfoot is not painful to the baby, however, even though it looks uncomfortable.

Nursing Care Plan Diagnosis

The diagnosis of clubfoot is based on the doctor’s examination of the baby’s feet after birth. While it is possible to detect clubfoot before birth during an ultrasound test, the ultrasound picture does not allow the doctor to determine how severe the deformity is. After the baby is born, the doctor can examine the foot by feeling the bones and soft tissue, measuring various parts of the foot and the leg muscles, and moving the joints in the foot to see how much range of motion is present in the ankle and toes. The office examination is often followed by an x-ray study of the foot to confirm the diagnosis and to provide a baseline measurement for the surgeon in case surgery is needed later on.

Nursing Care Plan Treatment

At one time surgery was the only available method of treatment for clubfoot. Since the early 2000s, however, several methods of splinting and bracing have been used to treat flexible clubfoot. The best-known method is the Ponseti method, which was developed by a Spanish doctor named Ignacio Ponseti (1914–) in the 1950s but was not widely used until Dr. John Herzenberg used the Internet to tell parents about the Ponseti method in 2000. The Ponseti method uses gentle placement of the baby’s foot into the correct position and keeping it there with a plaster cast. The foot is repositioned and placed in a new cast every few weeks for three to six months. The next stage is fitting the child with special shoes attached to a brace that is worn at night for two to three years.

The Ponseti method requires parents to actively participate in their child’s foot care; they must be sure that the child wears the brace and special shoes for the required length of time each day and that the shoes and brace are correctly applied. Children with resistant clubfoot are usually referred to an orthopedic surgeon (a surgeon who specializes in operations involving the bones and joints) around six to twelve months of age. The foot is x-rayed again so that the surgeon can plan the exact location of the surgery that is required.

At one time the same technique was used on all children with clubfoot regardless of the degree of correction that was needed, but surgical treatment of clubfoot is now highly individualized. The child is placed under general anesthesia and the surgeon lengthens or loosens certain ligaments or tendons so that the foot can develop normally. The surgeon can usually work only on soft tissues if the child is five years of age or younger. Children older than five, however, usually need to have certain bones in the foot reshaped or removed as well as changes made in the soft tissue of the foot.

Nursing Care Plan Prognosis
The majority of children with clubfoot can be treated with good or satisfactory results. The Ponseti method is reported to be successful in 89 percent of patients whose feet can be corrected without surgery. Children whose clubfoot must be treated surgically have good results in 81 percent of cases. The chief measure of satisfaction is the range of motion in the child’s ankle following surgery, as the ability to move the ankle freely determines how well the foot will function as the child grows.

The degree of deformity in the foot bones at the time of birth is the major factor that affects the success of surgery. Children who are older have better results in surgery than those who are younger than six months because the foot is larger and the surgeon can better determine the size and location of the tissues or bones that need to be corrected.

Nursing Care Plan Prevention

There is no known way to prevent clubfoot, because the causes of the deformity are not yet fully understood.

The Future
It is not likely that clubfoot will become significantly more common in the future than it is now. However, further refinements of the Ponseti method and further development of surgical techniques for correcting clubfoot should make it possible for most children to benefit from treatment for the condition.
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