Circulatory Shock, types and stages, compensatory mechanisms
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Club foot
1.
2. CLUBFOOT
๏ง VAGUETERM USEDTO DESCRIBE A
NUMBER OF DIFFERENTABNORMALITIES
INTHE SHAPE OFTHE FOOT
๏ง NOW IT HAS COMETO BE SYNONYMOUS
WITH THE COMMONEST CONGENITAL
FOOTABNORMALITY i.e., CTEV
7. ANATOMY
๏ง LIGAMENTS
๏บ DELTOID L. : MEDIAL COLLATERAL LIG. OF ANKLE
๏บ SPRING L. : CALCANIUM โ NAVICULAR
๏บ CAPSULAR L. :T โ N , N โ C , C โ M
๏บ PLANTAR L. :LONGITUDINAL ARCH OF FOOT
8. NOMENCLATURE
Planus: flatfoot
Cavus: highly arched foot
Varus: heal going towards
the midline
Valgus: heel going away
from the midline
Adduction: forefoot going
towards the midline
Abduction: forefoot going away
From the midline
10. CLUB FOOT
Definitions
Talipes: Talus = ankle
Pes = foot
Equinus: (Latin = horse)
Foot that is in a position of
planter flexion at the ankle,
looks like that of the horse.
Calcaneus: Full dorsiflexion at the ankle
14. CLASSIFICATION
๏ง EXTRINSIC
๏บ FLEXIBLEWITH ABNORMAL BONE RELATION
๏บ WITHOUT MARKED FIBROSIS
๏บ CONSERVATIVETREATMENT
๏ง INTRINSIC
๏บ RIGIDWITH ABNORMAL BONE RELATION
๏บ MARKED FIBROSIS
๏บ OPERATIVETREATMENT
15. THEORIES OF CTEV
๏ง TURCOโS : medial displacement of navicular and
calcaneous around talus
๏ง BROCKMANโS : congenital atresia of theT โ N joint
๏ง Mc- KAYโs :3-D bony deformity of the subtalar complex
๏ง INTRAUTERINE:compression by malpositon of fetus in utero
๏ง Germ plasm theory
๏ง Soft tissue theory
๏ง Prenatal muscle imbalance theory
16. PATHO-ANATOMY
๏ง BONES AND JOINTS
๏ CALCANEUS : INVARUS POSITION
๏ TALUS : DISPLACED MEDIAL AND PLANTARWARDS
๏ NAVICULAR : MEDIALLY DISPLACED AND ROTATED
๏ CUBOID : DISPLACED MEDIALLY AND ARTICULATES
WITHTHE NON-ARTICULAR SURFACE
OF CALCANEUM ( CUBOID SIGN /
LOCKED CUBOID )
๏ METATARSALS : DEVIATES MEDIALLY ATT-M JOINTS
๏ DISLOCATION OFTALOCALCANEAL ARTICULATION
๏ TIBIA โ MEDIALTORSION
21. PATHO-ANATOMY
๏ง SKIN
๏บ Adapts shortening on the medial side
๏บ Deep creases on the medial side
๏บ Dimples on the lateral aspect
๏ง SECONDARY CHANGES
๏บ Occurs when the child starts walking-exaggerates the
deformity
๏บ Callosities and bursae
22. CLINICAL FEATURES
๏ง COMMON PRESENTATIONS
๏บ Detected at birth
๏บ Infancy and early child hood
๏บ Late childhood
23. CLINICAL FEATURES
๏ง Short Achilles tendon
๏ง High and small heel
๏ง No creases behind Heel
๏ง Abnormal crease in middle of the foot
๏ง Foot is smaller in unilateral affection
๏ง Callosities at abnormal pressure areas
๏ง Internal torsion of the leg
๏ง Calf muscles wasting
๏ง Deformities donโt prevent walking
24. CLINICAL FEATURES
๏ง Seek a detailed family history of clubfoot or
neuromuscular disorders, and perform a general
examination to identify any other abnormalities.
๏ง Similar deformities are seen with myelomeningocele
and arthrogryposis.Therefore, always examine for
these associated conditions.
25. CLINICAL FEATURES
๏ง DORSIFLEXION TEST :
๏ง PLUMBLINETEST : tibial torsion
๏ child is made to sit on a table with both LL hanging from the
edge.
๏ Line drawn from the centre of the patella to the tibial tubercle
when extended down should cut the foot at 1st or 2nd
intermetatarsal space normally.- PLUMBLINE
๏ In CTEV , with medial rotation of tibia it cuts through 4th or 5th
space
๏ง SCRATCHTEST โ INFANTS
๏บ MEDIAL SCRACTHTEST : FOOT EVERTS - PERONEALS
๏บ LATERAL SCRACTHTEST: FOOT INVERTS - INVERTORS
26. INVESTIGATIONS
๏ง RADIOGRAPHY
๏บ APVIEW :angle formed b/w
๏ talus and calcaneum ( NORMAL 30-35)๏ REDUCED
๏ Talus and metatarsals ( NORMAL 5 -15 ) ๏ -VE
Helps to asses angle of varus and forefoot adduction
27. RADIOGRAPHY
๏บ LATERALVIEW - ANGLE FORMED B/W
๏ TIBIA AND CALCANEUM ( NORMAL 5- 15 ) ๏ -VE
๏ TALUS AND CALCANEUM ( NORMAL 20- 50) ๏
TO KNOWTHE EXTENTOF EQINUSANDVARUS DEFORMITY
๏ง CT , MRI , ARTHROGRAPHY
28. MANAGEMENT
The goal of treatment for clubfoot is to obtain a plantigrade foot
that is functional, painless, and stable
A cosmetically pleasing appearance is also an important goal
๏ง CONSERVATIVE
๏ง SURGICAL
๏ง EXTERNAL FIXATORS
29. CONSERVATIVE
๏ง INFANTS (< 6 MONTHS)
๏ง 1ST 6WEEKS : SERIAL MANIPULATION AND CASTING
๏บ Corrective casting
๏ First correction of adductus of midfoot
๏ Folowed by correction of inversion
๏ Finally correction of the equinus
30. Conservative management
Weekly serial manipulation and casting
Every weekly for 1st 6 week
Fortnightly till 6 months
Correction acheived Correction not achieved
Splint
day time
Phelpโs Brace
night time
Dennis Brown Splint
For 6 โ 18 mothhs
CTEV shoes
( upto 4 years )
SURGERY EXT. FIXATOR
<4YRS STR
>4YRS STR+BONY
PROCEDURE
31. SURGICAL TRATMENT
Indications
๏ง Late presentation, after 6 months of age
๏ง Complementary to conservative treatment
๏ง Failure of conservative treatment
๏ง Residual deformities after conservative treatment
๏ง Recurrence after conservative treatment
32. SURGICAL TREATMENT
๏ง Soft tissue operations
๏บ Release of contractures
๏บ Tendon elongation
๏บ Tendon transfer
๏บ Restoration of normal bony relationship
๏ง Bony operations
Usually accompanied with soft tissue operation
Types:
๏บ - Osteotomy, to correct foot deformity or int. tibial torsion
๏บ - Wedge excision
๏บ - Arthrodesis (usually after bone maturity)
๏บ one or several joints
๏บ - Salvage operation to restore shape
33. P M S R
POSTERO MEDIAL SOFTTISSUE RELEASE ( 6-12 months )
๏ง TURCOโS PROCEDURE
๏บ On the posterior Side
๏ Z- plasty of tendo โ Achilles
๏ Posterior capsulotomy of ankle and subtalar jnt
๏ Release of posterior talo-fibular and calcaneo-fibular lig
๏บ On the medial side
๏ Lenghtening ofTP , FHL, FDL
๏ Release of talonavicular lig., spring lig., superficial part of
deltoid lig.
๏ Release of interossious talocalcaneal lig, capsules of naviculo-
cuniform and 1st metatarsao-cuniform jnts
34. P M S R
๏บ On the plantar side
๏ Plantar fascia release
๏ Release of AH , FDB
๏บ Post โ op regimen
๏ Change cast at 2 weeks
๏ Remove K wire at 6 weeks
๏ Long leg cast for 3 months
๏ Ankle foot orthoses for 6- 9 months
35. LIMITED SOFT TISSUE RELEASE
๏ง When only one component present
๏บ Equinus โ posterior release
๏บ Adduction โ medial release
๏บ Cavus โ plantar release
36. CIRCUMFERENTIAL RELEASE
๏ง McKAYโs
๏บ All structures on PMSR + lateral structures
๏บ Superior peroneal retinaculam
๏บ Inferior extensor retinaculam
๏บ Dorsal calcaneo-cuboid lig.
๏บ 12 โ 36 months
๏บ Passively correctable deformity resulting from muscle
imbalance
37. RESISTANT CLUBFOOT
โข >5YR. METATARSAL OSTEOTOMY
METATARSUS
ADDUCTUS
โข <2- 3YR .modified McKeyโs procedure
โข 3- 10 yr
โข Dwyer osteotomy
โข Dilwyn โEvans operation
โข 10-12 yr tripple arthrodesis
HIND FOOT
VARUS
โข TendoAchillus lengthening + posterior capsulotomy sub
talar and ankle joint
โข Lambrunidis triple arthrodesis
EQINUS
38. OPERATIONS
๏ง TRIPPLE ARTHRODESIS(>10YRS)
๏บ Lateral closed wedge osteotomy through subtalar and
midtarsal joints is done to fuse
๏ SUBTALAR
๏ TALONAVICULAR
๏ CALCANEOCUBOID
๏ง TALECTOMY
๏บ Severe uncorrected club-foot
๏ง SURGERY FOR CORRECTION OFTIBIALTORSION
๏ง >15deg should be corrected by derotation osteotomy
39. DILWYN-EVANS OPERATION
๏ง Soft tissue release and calcaneocuboid fusion
๏ง 1st three stages : extensive soft tissue release
๏ง Finally calcaneaocuboid wedge is excised
๏ง Neglected or recurred foot in children of 4-8 yrs
40. EXTERNAL FIXATORS
๏ง ILIZAROVโS EXTERNAL FIXATOR FRAME
๏ง JOSHIโS EXTERNAL FIXATOR FRAME
๏ง Allows gradual distraction
๏ง Transfixing wires through
๏บ Tibia, calcaneum ad metatarsals
๏ง Distractors positioned
๏บ Posteriorly, medially and laterally
๏ง Frame completed by
interconnecting the components
41. TREATMENT IN ADULT PATIENT
๏ง CUNIFORMTARSECTOMY
๏บ Vertical wedge of bone , with its base laterally is
removed from
๏ Calcaneus โ behind the metatarsal joints
๏ Cuboid โ infront of the joint
๏บ Curved wedge , with its base upwards and laterally
๏ from head and neck of talus
42. RETENSION OF CTEV CORRECTION
๏ง DENIS BROWN SPLINT
๏ง PHELPโS BRACE
๏ง BELOW KNEEWALKING CALIPERS
๏ง CTEV SHOES