Neonatal talipes equinovarus

A child is sometimes born with shortening of the soft tissues of the flexor aspect of his leg, and the medial side of his foot, which causes his talus to point downwards (equinus), and inwards (varus). At the same time, his forefoot is adducted at its tarso- metatarsal joints. This may happen to one or both of his feet. If his deformity is very severe, his navicular bone may be pulled medially, and sometimes even away from the front of his talus. If his foot remains like this, its bones may break in the middle to form a ''rocker bottom foot'. Occasionally, he is born with his feet pointing in other directions. Some cases of talipes are due to paralyses, for example those associated with meningomyelocele (28.9).

You should be able to treat 75% of children with talipes using only non-operative methods[md]if you see them early enough and follow them up thoroughly. The remaining 25% will need expert surgery at some stage. Even if these children are not operated on, they can walk adequately and painlessly, although their feet are ugly, and will not fit into ordinary shoes.

When you treat a child with talipes try to: (1) Correct the position of his foot, as soon as possible after birth. (2) Hold it in a corrected position, until its bones have had a chance to grow in their new position. As soon as he starts walking, his foot is probably safe. Treatment must begin soon[md]it has been said that if a club foot is diagnosed at the beginning of a breech delivery, manipulation should start then! If treatment is delayed until a child is 6 months old, correction will take longer, but non-operative treatment is still worth trying, even as late as this. Any foot which is not fully corrected at 6 months needs surgery. Where skills and facilities are good, it is often done at 3 months, and sometimes as young as 6 weeks.

You have a choice of: (1) Zinc oxide strapping or, (2) plaster casts. Strapping has to be applied in such a way that each time a child kicks it pulls his leg straight. It can be applied by primary care workers, or by his mother[md]if she is sufficiently intelligent, and reliable, and you teach her carefully. Talipes and the strapping method have been described in ''Primary Child Care' (26.52), so that all primary health workers should know about it, and how important it is to start treatment early. Some of them may be able to apply it. The strapping method needs a certain skill to do well, and careful supervision.

Plaster casts are more reliable, but they have to be applied in a hospital outpatient department, preferably by yourself, or a carefully trained and supervised orthopaedic assistant, or other paramedical. The disadvantage of strapping is that a less educated village mother may remove it, or not realize that it needs replacing as soon as it becomes loose, so her child may be better with a cast; but she must bring him every two weeks to have it changed.

There are two types of talipes equinovarus: (1) False talipes which is positional only, and does not need treatment, and (2) true talipes which does. There are two varieties of true talipes, (2a) an easy type which responds readily to treatment, and (2b) a resistant type, which does not. You will not know which type a child has, until you have treated him for a few weeks. Rarely, the condition of his muscles which causes his talipes also involves his other muscles, and makes them rigid. This is arthrogryposis.

Fig. 27-17 STRAPPING FOR TALIPES. A, the consequences of neglect. Fortunately, this child's deformed feet are not likely to be painful. B, the first piece of strapping. When this is on the child's foot must be in its normal shape. C, the second and third pieces of strapping. Kindly contributed by John Biddulph.

TALIPES TRUE OR FALSE TALIPES? Can you bend a newborn baby's ankle, so that the outer side of his foot touches the outer side of his leg? If you can, he has false talipes and he needs no treatment. If you cannot do this, he has true talipes.

MANAGING TRUE TALIPES. [f41]If there is no cleft on the inside of his foot or his heel, his talipes is sufficiently mild for non-operative treatment to have a good chance of success[md]especially if it starts in the first day or two after birth.

If there is a cleft on the inside of his foot or his heel, his talipes is too severe for non-operative treatment, so refer him to an expert early. Operative treatment can start as early as 3 weeks under ideal conditions, and should be done by 6 months. 3 months is a good compromise. Meanwhile treat him non- operatively.

If he is a true arthrogrypotic, with multiple other deformities, refer him, but it is doubtful if any treatment is worthwhile.

CAUTION ! (1) Start non-operative treatment as soon after birth as possible. (2) Look for other congenital abnormalities, especially spina bifida. Make sure he can move his legs. If he also has a meningomyelocele, he will also be incontinent of urine, and treating his feet will not be worthwhile.

ZINC OXIDE STRAPPING [s7]FOR TALIPES Use zinc oxide strapping. Elastic strapping will not work. If possible, put tincture of benzoin on his leg before you apply the strapping. This will stick it to his leg, and help to prevent sores.

Put pieces of cotton wool over his knee, behind his toes, and on his lateral malleolus. Put the first long piece of strapping (1, in Fig. 27-17) from under his heel up over the cotton wool outside his ankle. Bring it up outside his leg, and over the cotton wool on the top of his knee. Bend his ankle straight, as you put on this strapping. When this piece of strapping is on, his foot must be in its normal shape.

Put on a second piece of strapping (2) round his foot near his toes, up the outside of his leg and his knee.

Put a third piece (3) round his leg. This will keep the two long pieces in place.

Count all his toes and make sure they are pink and warm. If they are blue and cold, you have stopped the blood flowing. This is dangerous. Take the strapping off, and put it on looser. When his feet have been successfully strapped, raise his feet on a pillow as much as possible, especially for the first 5 days. Change the strapping twice a week for a month, then once a week until he is four months old. Follow him up as for a cast (see below).

Fig. 27-18 CASTS FOR TALIPES. A, a child with the common type of talipes has an equinus and varus deformity of his ankle, and an adduction deformity of his forefoot. B, first pad his leg well. C, apply the cast. While it is still wet, hold his foot 10[de] above the neutral position, with his forefoot abducted. Overcorrect it a little, so that his foot is in slight valgus and is slightly everted. Kindly contributed by John Stewart.

PLASTER CASTS [s7]FOR TALIPES Let him suck quietly at his mother's breast. There is no need for anaesthesia. Practise manipulating his foot before you apply the cast.

Apply a thin sheet of cotton wool padding from his upper thigh to his toes, with his knee bent to 90[de]. Apply the cast in two stages. Immobilize his bent knee in plaster first. With his knee immobile, you can then plaster his foot in the correct position more easily.

Use a narrow (2.5 cm) plaster bandage, to immobilize his bent knee. When this has set, extend it by applying a cast from his toes, leaving them visible. As this sets, push his foot into as much dorsiflexion, and eversion of his ankle, as he will tolerate. As you do this, press behind his metatarsal heads rather than over them, or you will give him a rocker-bottom foot.

When the cast has set, add extra plaster as required, and smooth and trim its edges. Raise his feet on a pillow as much as possible, especially for the first 5 days.

Ask his mother to bring him back to have his cast changed, at first every week, and then every two weeks. If they live far away, every 4 weeks is acceptable. In the wet season, casts don't last long, so if necessary she should come more often. Before you see him, arrange to have his cast removed, under sedation if necessary, for example with chlorpromazine or promethazine elixir 2.5 mg/kg.

CAUTION ! (1) His toes must be visible. (2) Don't leave a deep thumb mark over his anterior tendons, or they will slough. (3) This is a circular cast, but it is not practicable to split it (70.3). Gangrene of the foot can occur, so warn his mother that if his foot becomes cold or blue, or he cries excessively, she must come back immediately. If she lives far away, she must soak off the plaster immediately.

FOLLOW UP. As soon as his deformity is fully corrected, hold it like that for at least a further 6 more months. If it is fully corrected, take off his cast when he starts walking[md]not before.

Follow him carefully until he is walking normally, and you are sure that his foot is normal and not relapsing. See him regularly until he is at least 5.

Refer him for surgery if: (1) his Achilles tendon is still too short at 3 months. (2) He shows any tendency to relapse. (3) His deformity is not fully corrected when he starts walking.

DIFFICULTIES [s7]WITH TALIPES If at 3 months a child is NOT RESPONDING TO TREATMENT, he probably has the resistant type of talipes, so refer him for surgery as soon as you can. When he has been operated on, continue to apply casts or strapping until he is ready to start walking.

If his FOOT IS DORSIFLEXED (rare), it will usually be in valgus also (talipes calcaneovalgus). Make sure his hip is not dislocated at the same time. This deformity usually disappears spontaneously. If it is severe and persistent, manipulate and splint it.

If his FOREFOOT IS ADDUCTED only, you will probably be able to correct it by manipulation and splinting.