The parent of a newborn diagnosed with clubfoot asks the nurse how to care for the bilateral toe to thigh casts. For each instruction listed , click to indicate whether it is appropriate or inappropriate for the nurse to recommend.

Clubfoot: Nursing

Content Reviewers

Viviana Popa, MD,Lisa Miklush PhD, RN, CNS

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Anca-Elena Stefan, MD,Bailey Opsal, RN,Evan Debevec-McKenney,Abbey Richard, MSc

Clubfoot, also called talipes equinovarus, is a complex congenital deformity that involves the ankle and foot. Let’s start by looking at the anatomy and physiology of the newborn’s foot. The foot is essential for stability, locomotion, balance and development of motor skills, so it’s important that the structures comprising the foot are well-developed. There are 3 regions of the newborn foot: hindfoot, also called rearfoot; midfoot; and forefoot. The hindfoot includes two bones: the talus and calcaneus. The midfoot includes the navicular bone, the cuboid bone and the cuneiform bones. Finally, the forefoot consists of metatarsals, which are the long foot bones; and the phalanges, which are the toe bones. Unlike the adult foot, the newborn arch is flat; has a greater range of motion and consists of more subcutaneous fat. The ankle is a synovial joint that results from interaction between the ends of the tibia and fibula, which are the bones of the lower leg, that allows the foot to move up and down.

Now, the ultimate cause of clubfoot isn’t fully known, but causes can be classified as idiopathic, syndromic, or positional. If clubfoot is an isolated anomaly in an otherwise healthy neonate, it’s considered to be idiopathic. Sometimes, though, clubfoot can be syndromic, which means it’s associated with other genetic or anatomic abnormalities. Other times, the cause is positional, like with oligohydramnios, where there’s not enough amniotic fluid, or because of changes within the uterine environment that creates pressure on the fetal extremity during critical periods of development. All right, now, when it comes to pathology, clubfoot is associated with bone deformities and soft tissue contractures. There are four main components, which can be remembered by the acronym CAVE. The first one is an exaggerated arch, also known as Cavus. Second, there’s forefoot Adduction with supination, meaning that the forefoot is inverted and turned upwards.Third, inversion of the heel and hindfoot, which is called talipes Varus. Finally, there’s plantar flexion of the foot, meaning the heel is raised and the ankle is in a pointed-toe position, which is called talipes Equinus. All these components together create clubfoot, which can be unilateral or bilateral.

CLUBFOOT
	KEY POINTS	NOTES
DEFINITION	Complex congenital deformity that involves the ankle and foot
PHYSIOLOGY	Newborn foot Hindfoot Talus Calcaneus Midfoot Navicular bone Cuboid bone Cuneiform bones Forefoot Metatarsals Phalanges Arch is flat Greater range of motion Consists of more subcutaneous fat Ankle is synovial joint resulting from interaction b/n tibia and fibula
CAUSES AND RISK FACTORS	Causes Idiopathic Isolated anomaly Syndromic Associated w/ genetic or anatomic abnormalities Positional Changes within uterine environment Pressure on fetal anatomy
PATHOPHYSIOLOGY	Unilateral or bilateral Bone deformities Soft tissue contractures CAVE Complications Inability to bear weight on affected foot Abnormal gait Disturbances in foot growth Rocker-bottom foot
SIGNS AND SYMPTOMS	CAVE deformities Flexibility ranging from stiff to flexible
DIAGNOSIS	Fetal ultrasound Newborn assessment Pirani system
TREATMENT	Non-surgical Manipulation Serial casting Corrective shoes Surgical
MANAGEMENT OF CARE	Goals of care Maintain neurovascular integrity Maintain skin integrity Apply cast Provide post-op care Assess and manage pain Neurovascular checks Skin assessment Elevate foot Reposition foot Notify HCP Cyanosis Immobility Lack of sensation
PATIENT AND FAMILY TEACHING	Explain condition, plan of care, and safe medication administration Casting Check feet/toes for color, sensation, and temperature Capillary refill Cast care Keep clean/dry Top of cast avoid diaper area Never insert object into cast Elevate casted extremity Brace may need to be worn for 23 hours/day for months and at night for years Notify HCP Skin turns a dark or bluish color Loss of sensation Child can't wiggle toes

Clubfoot: Nursing

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