Orthopedic Disorders

IVY MAY V. MARBELLA MAN, RN

ASSESSMENT
Management of orthopedic patients
begins with an accurate assessment of
the patient's specific problems.
Important information can be obtained
from the patient's history and the
physical assessment.
Diagnostics

1.Radiography
2.Nuclear Medicine ( CT, PET,
Myelography, Arthrography,
Arthrocentesis, Electromyography,
MRI)
Lab Tests

1. Serum calcium phosphorous

2. Acid and alkaline level determination

3. Phosphatase determination
Nursing Diagnosis

ACUTE PAIN
a. Most patients with disorders of bones, joints, and muscles experience pain.
Orthopedic nursing assessment and management of pain must be individualized
as each person will have a different threshold and tolerance for pain.
b. Bone pain is described as a deep, dull, boring ache, as opposed to muscle
pain, which is described as a soreness or aching
c. Increasing pain may indicate an infectious process, malignancy, or vascular
problem. Pain that increases only with activity may indicate joint or muscle sprain.
d. Sharp pain may be related to a bone infection with muscle spasm, pressure on
a sensory nerve, or fracture pain, which is both sharp and piercing.
e. Radiating pain is seen in conditions where pressure is exerted on
a nerve root.
NURSING INTERVENTION FOR
PAIN:
(1) Repositioning
(2) Support
(3) Circulation
(4) Medication
OSTEOARTHRITIS(OA)
• Degenerative Joint Disease A.K.A. “Wear and
Tear Arthritis”
• occurs when the cartilage that cushions the
ends of bones in your joints gradually
deteriorates.
• affects weight bearing joints and joints of the
distal interphalangeal, proximal
interphalangeal joints of the fingers.
OSTEOARTHRITIS(OA)
RISK FACTORS

OBESITY
MECHANICAL JOINT STRESS
JOINT TRAUMA
CONGENITAL AND
DEVELOPMENTAL DISORDERS OF
THE HIP, PREVIOUS BONE AND
JOINT DISORDERS,
INFLAMMATORY JOINT DISEASE,
ENDOCRINE AND METABOLIC
DISEASE
CLASSIFICATION

1. PRIMARY(IDIOPATHIC)
No known cause
Localized OA in one or two joints
Generalized OA in three or more joints
More common in women (slightly)
More common in Caucasians
Develops in middle age and progress

2. SECONDARY(RELATED TO RISK FACTOR)

Signs and Symptoms
+ BRIEF JOINT STIFFNESS
+ PAIN AFTER PERIOD OF
ACTIVITY

+ JOINT ENLARGEMENT
+ HANDS-HEBERDEN’S NODES
+ BOUCHARD’S NODES
+CREPITUS
Medical/Surgical Management

LARGE DOSE OF
ACETAMINOPNHEN
NSAID’S, ASPIRIN, AND
CORTICOSTEROIDS
RECONSTRUCTIVE
SURGERY
KNEE AND HIP
REPLACEMENT
Prevention

WEIGHT REDUCTION
PREVENTION OF INJURIES
PERINATAL SCREENING FOR CONGENITAL HIP DISEASE
ERGONOMIC MODIFICATIONS
NURSING MANAGEMENT
REST
HEAT APPLICATION
WEIGHT REDUCTION
PHYSICAL THERAPY
TENS-TRANSCUTANEOUS
ELECTRICAL NERVE STIMULATION
Charcot’s Joint
called neuropathic joint disease
Multicausal degeneration and deformation of joint
Etiology:
a.Diabetes mellitus
b. syringomyelia
c.Tertiary syphilis
d.Peripheral neuropathies
e.Spina bifida
f.Leprosy
g.Multiple sclerosis
h.Long term intra-articular steroid injections
S/S

a. Inspection: foot is everted, widened,

and shorter than normal
b. Examination
1.Joint instability
2.Soft tissue swelling
3.Pain secondary to inflammation
 Diagnostics

a. Laboratory analysis of synovial fluid

1.Fluid is non-inflammatory
2.Low protein content
3.No hemorrhage noted
b. Radiographs
Medical Management

a.Conservative treatment
1.Protection from overuse/abuse
2.Braces and splints
b.Surgical management:
Fusion of the involved joint
Nursing Interventions

a.Goal: Preserve the joint

b.Patient education can prevent further
injury
c.Protection of the joint
1.Braces
2.Orthopedic shoes
d.Prolonged immobilization
1. 8 to 12 weeks to decrease swelling
2. Leads to minimal joint deformity
and a functional painless foot
 Chondromalacia patellae
(also called patello femoral arthralgia)
Progressive, degenerative softening of the bone;
follows a knee injury
Etiology

a.Lateral subluxation of the patella

(kneecap)

b. Direct or repetitive trauma to the

patella produces chondral fracture

c. Underdevelopment of the
quadriceps muscles
Signs and Symptoms

a.Pain with flexed knee activities (poorly

localized)
b.Mild swelling
c.Occasional episodes of buckling of
the affected knee
d.Minimal joint effusion
e.Evidence of 'squinting kneecaps'
f.Atrophy of quadriceps
g.Inverted 'J' tracking of the patella in
the final 30 degrees of extension
h.Excessive quadriceps angle
j.Crepitation upon range of motion
Diagnosis

a.Radiographs
b.Bone Scans
c.MRI Scans
d. Arthroscopy
Conservative Medical Management

a. Progressive resistive exercises

1.Quadriceps setting - isometric
2.Hamstrings - isotonic
b. Medication: NSAIDs
c. Nonmedication assistance: application of ice
or moist heat
d. Activity restriction
Surgical Management

a.Indicated if symptoms remain after

6 months of conservative treatment
b.Arthroscopy
c. Arthrotomy
1.Realignment of proximal
and/or distal soft tissue
2.Tibial tubercle elevation
3.Patellectomy - Surgical
removal of the patella.
INFLAMMATORY DISORDERS
RHEUMATOID ARTHRITIS(R.A)

Is an inflammatory
disorder that primarily
involves the synovial
membrane of the
joints.
 OCCURS BETWEEN THE AGES OF
30 AND 50 YEARS, WITH PEAK
INCIDENCE BETWEEN 40 AND 60
YEARS OF AGE.
 WOMEN ARE AFFECTED TWO TO
THREE TIMES MORE
FREQUENTLY THAN MEN.
 RA IS BELIEVED TO BE
AUTOIMMUNE RESPONSE TO
UNKNOWN ANTIGEN.
 THE STIMULUS MAY BE VIRAL OR
BACTERIAL.
CLINICAL MANIFESTATION

CLASSIC SYMPTOMS
 JOINT PAIN
 SWELLING
 WARMTH
 ERYTHEMA
 LACK OF FUNCTION
 PALPITATION OF JOINTS
REVEALS SPONGGY OR
BOGGY TISSUE.
 FLUID CAN USUALLY BE
ASPIRATED FROM THE
INFLAMED JOINT.
CHARACTERISTIC PATTERN OF JOINT INVOLVEMENT

BEGINS WITH SMALL JOINTS IN HANDS, WRISTS AND FEET

PROGRESSIVELY INVOLVES KNEES, SHOULDERS, HIPS,
ELBOWS, ANKLES, CERVICAL SPINE, AND
TEMPOMANDIBULAR JOINTS
SYMPTOMS ARE USUALLY ACUTE IN ONSET, BILATERAL AND
SYMETRIC
CHARACTERISTIC PATTERN OF JOINT
INVOLVEMENT-OFTEN RAPIDLY PROGRESSIVE
AND DESTRUCTIVE DISEASE

ARTERITIS
NEUROPATHY
SCLERITIS
PERICARDITIS
SPLENOMEGALY
SJOGREN’S SYNDROME
MEDICAL MANAGEMENT
PHARMACOTHERAPHY
ASPIRIN
NSAID’S-SALICYLATES (ANTI-INFLAMMATORY AND
ANALGESICS
CORTICOSTEROIDS-OPOID ANALGESICS,
METHOTREXATE (RHEUMATREX)
DEMEROL/MORPHINE
BETHAMETHASONE
DICLOFENAC, NAPROXEN, KETOROLAC, IBUPROFEN
SURGERY

OSTEOTOMY
SYNOVECTOMY
ARTHROPLASTY

PHYSICAL THERAPY
Nursing Diagnosis
SELF CARE DEFICITS
Pain
Fatigue
DISTURBED SLEEP PATTERN
DISTURBED BODY IMAGE
INEFFECTIVE COPING
(ACTUAL/PERCEIVED
LIFESTYLE)
 NURSING MANAGEMENT

• BED REST DURING ACTIVE PHASE

• PASSIVE ROM EXERCISES OF JOINTS
• SPLINT PAINFUL JOINTS
• HEAT AND COLD APPLICATION
• WARM BATH IN THE MORNING
• PROTECT FROM ANY SECONDARY INFECTION
GOUT

an acute, recurrent
disease characterized
by painful
inflammation of the
joints, chiefly those in
the feet and hands,
and esp. in the great
toe, and by an excess
of uric acid in the
blood.
PATHOPHYSIOLOGY
THERE IS AN
OVERSECRETION OF
URIC ACID, OR A
RENAL DEFECT
RESULTING IN
DECREASED
EXCRETION OF URIC
ACID OR A
COMBINATION OF
BOTH.
HYPERURICEMIA

EXCESIVE INTAKE OF FOODS HIGH IN PURINES(SHELLFISH, ORGAN

MEATS OR HEREDITY.
CLINICAL MANIFESTATIONS

 4 STAGES OF GOUT
1. ASYMPTOMATIC
HYPERURICEMIA
2. ACUTE GOUTY ARTHRITIS
3. INTERCRITICAL GOUT
4. CHRONIC TOPHACEOUS
GOUT

Medical DX: Serum Uric Acid

Levels
N 3.5-7.2 mg/dl
treatment
Medical
NSAID’s, Colchicine,
Benemid, allupurinol
Heat and cold
therapy

 Diet
Avoid purine foods
such as meats, organ
metas, shellfish,
sardines, and yeast
Nursing management
Pain management strategies
Elevate the affected limb, provide
bedrest and immobilize joint
Reinforce dietary management
Weight control
Administer anti-gout medications
Increase fluid intake
OSTEOMYELITIS

IS AN INFECTION OF THE BONE AND

SURROUNDING SOFT TISSUE
CAUSES:
A) STAPHYLOCOCCUS AUREUS(70%-80%)
B)PSEUDOMONASAEROGINOSA
C) ESCHERICHIA COLI
SIGNS AND SYMPTOMS
MALAISE, FEVER
PAIN AND TENDERNESS OF BONE,
REDNESS AND SWELLING OF THE
BONE
DIFFICULTY WITH WEIGHT
BEARING
SEQUESTRUM(DRAINAGE FROM
WOUND SITE MAY BE PRESENT,
NECROSIS OF THE BONE)
MUSCLE WEAKNESS FROM
CALCIUM DEFICIENCY
WADDLING OR LIMPING GAIT;
LEGS BOWED IN MORE
ADVANCED DISEASE
WEAKNESS AND UNSTEADINESS,
PRESENTING RISK OF FALLS AND
FRACTURES
DIAGNOSTIC EXAMINATION

CBC
BONE
SCAN
X-RAY
MRI
MEDICAL AND SURGICAL MANAGEMENT

PROMOTE ADEQUATE INTAKE OF CALCIUM AND VITAMIN D AND A

NUTRITIOUS DIET IN DISADVANTAGED ELDERLY PATIENTS
ENCOURAGE PT. TO SPENDTIME IN THE SUN.
ANALGESICS
ANTIBIOTICS-IV 3-6 WKS. ORAL 3 MOS.
SURGICAL BONE DEBRIDEMENT
NURSING MANAGEMENT
IMMOBILIZATION OF THE AFFECTED PART
MAINTAIN PROPER BODY ALIGNMENT AND CHANGE
POSITIONS FREQUENTLY
STERILE TECHNIQUE
PSYCHOLOGICAL SUPPORT
COMPLICATIONS
SEPTICEMIA
THROMBOPHLEBITIS
MUSCLE CONTRACTURES
PATHOLOGIC FRACTURE
POTT'S DISEASE

Pott's carries, David's disease,

Pott's curvature, tuberculous
spondylitis
most commonly localized in the
thoracic portion of the spine
MYCOBACTERIUM TUBERCULOSIS
Risk factors:
• Endemic TB
• Low socio economic status
• HIV
Signs and symptoms:
back pain
fever
night sweating
anorexia
weight loss
Spinal mass, sometimes
associated with numbness,
tingling, or muscle weakness of
the legs
Late complications
severe kyphosis
sinus formation
paraplegia (so called Pott's paraplegia)
Vertebral collapse resulting in kyphosis
Spinal cord compression
paraplegia (so called Pott’s paraplegia)

Diagnostics
blood tests - elevated erythrocyte
sedimentation rate
tuberculin skin test
radiographs of the spine
bone scan
CT of the spine
bone biopsy
MRI
METABOLIC BONE DISORDERS
OSTEOMALACIA
softening of the bones, caused by not
having enough vitamin D, or by
problems with the metabolism
(breakdown and use) of this
vitamin.
In children, the condition is called
rickets

Conditions that may lead to

osteomalacia include:
1. Not enough vitamin D in the diet
2. Not enough exposure to sunlight
3. Malabsorption of vitamin D by the
intestines
Other conditions that may cause osteomalacia include:

1. Hereditary or acquired disorders of

vitamin D metabolism
2. Cancer

CONTRIBUTORY FACTORS: (reduce

formation of vitamin D)
1. Use of very strong sunscreen
2. limited exposure of the body to sunlight
3. short days of sunlight
SYMPTOMS:
1. Bone pain
2. Muscle weakness
3. Fractures with a very little
trauma
4. Numbness of the
extremities
5. Spasms over hands or feet
6. Abnormal heart rhythms
Osteoporosis

a.Multifactorial disease
results in
1.Reduced bone mass
2.Loss of bone strength
3.Increased likelihood of
fracture
Types
1.Type I osteoporosis (estrogen related)
TYPE I OSTEOPOROSIS
A. Loss of trabecular bone after menopause
B. Theoretically related to a lack of estrogen
c. Amenorrhea in younger women
Result to:

a. Loss of height
b. Kyphosis
c. Increased risk fracture
2.Type II osteoporosis (related to old age)
TYPE II OSTEOPOROSIS
A. Age-related loss of cortical/trabecular bone in
men and women occurring after age 70
B. Long-term remodeling
C. Results in fractures of humerus and femoral
neck
 
Signs and Symptoms
a.Client History
1.Acute fracture
2.Prior history of a traumatic
fracture; no trauma
3.History of falls
b.Pain
1.Greater when active, less while
resting
2.Early in disease, pain in mid to
low thoracic spine
d.Kyphosis - 'Dowager's hump' may
reflect multiple spinal fractures
e.Loss of height
Medical Management
a.Exercise
1.Restorative - aims to increase bone density, decrease risk for
fracture
2.Within the patient's tolerance
3.Must be maintained throughout life
b.Nutrition
1.Calcium and vitamin D
2.Deficiencies increase risk of fracture
3.Sedentary older adults may need supplements
c.Medication
1.Anti-resorptive agents
2.Biophosphonates
3.Bone-Forming Agents
a.Sodium Fluoride
b.Androgens
Nursing Intervention: Teach Prevention of Osteoporosis and Its
Damage
a. Education
1.Increase awareness
2.Discourage risk-related behaviors
3.Reinforce positive behaviors and lifestyles
b. Reduce risk of falling
1.Teach proper lifting techniques
2.Encourage proper footwear
3.Install safety equipment in home
PAGET’S DISEASE
otherwise known as
osteitis deformans
a chronic disorder that
typically results in
enlarged and deformed
bones
excessive breakdown and
formation of bone tissue
can cause bone to weaken,
resulting in bone pain,
arthritis, deformities, and
fractures.
CAUSE:

slow virus infection (i.e.,

paramyxoviruses such as
measles)

INCIDENCE:
Men are more commonly
affected than women
rarely diagnosed in people
less than 40 years of age
Symptoms:
Sometimes, symptoms may be
confused with those of
arthritis or other disorders.
In other cases, the diagnosis is
made only after complications
have developed. Symptoms can
include:
1. Bone pain is the most
common symptom.
2. Headaches and hearing loss
may occur when Paget's
disease affects the skull.
TREATMENT:
Bisphosphonates: taken on an empty stomach.
a.) Didronel (etidronate disodium) : 200– 400 mg once
daily for 6 months; tablet
b.) Aredia (pamidronate disodium) : IV
30 mg infusion over 4 hours on 3 consecutive days.
c.) Fosamax (alendronate sodium) : Tablet; 40 mg once
daily for 6 months
Calcitonin
eg. Miacalcin is administered by injection;
50 to 100 units daily or 3 times per week for
6-18 months
Surgery : Fractures -- Surgery may allow
fractures to heal in better position. Eg.
OSTEOTOMY > Cutting and realignment of
Pagetic bone.
Diet and exercise: 1000-1500 mg of calcium,
adequate sunshine, and at least 400 units of
vitamin D daily.
avoiding weight gain, and maintaining joint
mobility
Carpal tunnel syndrome

Pain or numbness that

affects some part of the
median nerve distribution
of the hand (the palmar
side of the thumb, the
index finger, the radial half
of the ring finger, and the
radial half of the palm)
and may radiate into the
arm.
Symptoms
 frequent burning
 tingling, or itching numbness in the palm of the hand and
the fingers, especially the thumb and the index and middle
fingers.
 Some carpal tunnel sufferers say their fingers feel useless
and swollen, even though little or no swelling is apparent.
 The symptoms often first appear in one or both hands
during the night,
since many people sleep with flexed wrists. A person with
carpal tunnel syndrome may wake up feeling the need to
"shake out" the hand or wrist.
 As symptoms worsen, people might feel tingling during the
day.
 Decreased grip strength may make it difficult to form a fist,
grasp small objects, or perform other manual tasks.
 In chronic and/or untreated cases, the muscles at the base
of the thumb may waste away.
 unable to feel between hot and cold by touch.
Diagnosis:

A physical examination of
the hands, arms,
shoulders, and neck
The wrist is examined for
tenderness, swelling,
warmth, and
discoloration.
Routine laboratory tests
and X-rays
Tinel test
electrodiagnostic tests
Prevention

• take frequent rest breaks,

wear splints to keep wrists
straight, and use correct
posture and wrist position.
• Wearing fingerless gloves
can help keep hands warm and
flexible.
• maintain a natural position
during work. Jobs can be
rotated among workers.
CONGENITAL MALFORMATION
CONGENITAL HIP
DISLOCATION
a hip problem also known as
Congenital Hip Dysplacia
where the ball at the top
of the thighbone (femoral
head) does not sit securely
in the socket (acetabulum)
of the hip joint.
Symptoms

Newborn:
1. Limited abduction of the
flexed hip t less than 50
degrees.
2. ORTOLANI’s SIGN >
“clicking” sound when the
newborn’s legs are pushed
apart.
Child (if undetected during
NB):
3. affected leg will look
shorter than the other one
4. skin folds in the thighs will
appear uneven
3. Less flexibility on the
affected side
4. When he starts to walk,
he’ll probably limp, walk on
his toes, or “waddle” like a
duck.
5. GALEAZZI’s / ALLIS’ sign
> child is placed on a firm
surface with the hips and
knees flexed. The knee will
appear lower on the
dislocated side.
Diagnosis

1. X-RAY > can confirm the diagnosis

2. TRENDELENBURG Test > normally, when standing
on one leg, contraction of the abductor muscles on
the side bearing weight will cause the opposite
side of the pelvis to be elevated.
> if hip is dislocated, muscles will no longer work
effectively, thus, when a child stands, the
opposite side of the pelvis drops downward.
Treatment

1. PAVLIK HARNESS > maintains

the hip in a more natural
position and prevents full
extension of the adducted
position.
> worn for 6 weeks.
2. Closed reduction > done under
anesthesia
3. Open surgery > to reposition
the hip
4. Following either the closed or
open procedure, the child will
wear a cast and/or braces for
several months.
Cerebral Palsy

 Group of non-
progressive, non-
contagious conditions
that cause physical
disability in human
development.
 CEREBRAL > refers to
the affected area of the
brain (CEREBRUM).
 PALSY > refers to
disorder of movement.
Classifications

1. Spastic CP > most common, occuring in 70-

80% of all cases.
a.) Spastic Hemiplegia > one side is affected.
b.) Spastic Diplegia > lower extremities are affected
more than the upper extremities.
3. Athethoid/Dyskinetic CP
mixed muscle tone:
HYPTONIA or
HYPERTONIA
Trouble holding themselves
in an upright position, steady
positions, and shows
involuntary motions.
Unable to hold objects
Damage to the basal ganglia
Occurs in 40% of all cases
Incidence

Ratio- 2 : 1,000 live births

Higher in males than females
CONTRIBUTORY CAUSES:
1. Hypoxia of the brain
during childbirth
2. Premature birth
3. Common in multiple
births/pregnancies
4. SBS > physical brain
injury leading to hypoxia
S/S

1. Abnormal muscle tone and

posture
2. Abnormal motor
development and
coordination
3. Joint and bone deformities
and contractures
4. Spasticity and involuntary
movements
5. Problems with balance
6. Congenital birth defects:
small jawbone, small head
7. Mental retardation as child
grows
Treatments

1. Physical Therapy > designed to encourage the

patient to build a strength base for improved
gait.
2. Occupational Therapy > maximizes function &
to adapt to their limitations & live as
independently as possible.
3. Orthotic Devices > makes use ankle foot
orthoses > to minimize gait irregularities and to
improve ambulation.
Scoliosis

Abnormal / lateral curvature of the

spine.
Classifications:
1. STRUCTURAL > congenital
abnormalities in the spine.
> neurofibromatosis
> idiopathic : no known cause;
accounts to 90% of all scoliosis.
2. Non- STRUCTURAL
Cause

Unknown
May result from a birth defect

CLINICAL FEATURES:
1.Dextro Scoliosis- spine bulges toward the right
when the curvature is in the back either thoracic or
lumbar.
2. Levo Scoliosis - spine bulges to the left either at
the thoracic or lumbar.
LEVO SCOLIOSIS

>
Other clinical features:
Right shoulder is usually higher than the left
One hip maybe higher than the other.
Symptoms

Mild scoliosis usually causes no symptoms

back becomes sore or stiff after the
child sits or stands for a long period of
time
Worsening scoliosis may eventually cause
permanent problems, such as noticeable
deformities or chronic pain
Severe scoliosis may even affect internal
organs, for example, deforming and
damaging the lungs
Diagnosis

routine physical examination >

a doctor asks the child to bend
forward and views the spine
from behind (Adam’s Test)
X-ray (Roentgenogram) studies
show the precise angles of
curvature
Cobb method > use of an x-ray
to measure the severity of the
curve; upper and lower
vertebrae are identified.
Treatment

Milwaukee brace /
Thoracolumbosacral
Orthotic (TLSO) >
object used to hold the
spine or to keep the
spine straight.
> worn for 23 hours a
day.
> worn for 2-3 years or
longer
> indicated for scoliosis
with 20-40 degrees
angulation.
Spinal Fusion > for severe cases
(40-50 degrees angle) with
Harrington Rod Instrumentation.
> surgical management wherein a
metal rod is inserted to keep the
spine straight until the vertebrae
have bonded permanently.
Exercise > performed with the
brace to improve cosmetic
appearance and to decrease the
curvature.
Kyphosis

curving of the spine that

causes a bowing of the
back, which leads to a
hunchback or slouching
posture.
Adolescent kyphosis, also
known as Scheuermann's
disease : shoulders are
rounded and drooped and
the abdomen maybe
protuberant.
Causes

Can result from trauma

Infection (tuberculosis)
Spina bifida > a birth
defect involving the
incomplete formation of
the part of the spine.
Paget’s disease
Polio
Tumors
S/S
Dx Tests

Physical examination
spine x-ray done to document
the severity of the curve
pulmonary function tests may be
used to assess whether the
kyphosis is affecting breathing
MRI > If there is any question of
a tumor, infection, or neurologic
symptoms
 Treatment

Scheuermann's disease is initially treated

with a brace and physical therapy
surgery is needed for large (greater than
60 degrees), painful curves.
Possible Complications

Disabling back pain

Neurological symptoms
including leg weakness
or paralysis
Decreased lung capacity
Round back deformity
Lordosis

is a medical term used to

describe an inward curvature
of a portion of the
vertebral column.
Two segments of the
vertebral column, namely
cervical and lumbar, are
normally lordotic, that is,
they are set in a curve that
has its convexity anteriorly
(the front) and concavity
posteriorly (behind), in the
context of human anatomy.
Treatment

•medication, to reduce pain and swelling.

•daily physical therapy, to strengthen
muscles and range of motion.
•weight loss, to help posture.
•braces, in children and teens.
•surgery, in severe cases with neurological
concerns.
•nutritional supplements such as vitamin D.
Congenital Foot Deformities

Calcaneovalgus foot
•ankle joint dorsiflexed, subtalar
joint everted
• classic positional deformity
• more common in 1st born, LGA,
twins
• 2-10% assoc b/w foot
deformity and DDH
• treatment requires stretching:
plantarflex
and invert foot
• excellent prognosis
Talipes Equinovarus (congenital
clubfoot)
A.General
- complicated, multifactorial
deformity of
primarily genetic origin

- 3 basic components
(i) ankle joint
plantarflexed/equines
(ii) subtalar joint
inverted/varus
(iii) forefoot
D. Diagnosis/Evaluation
- distinguish mild/severe
forms from other disease
- AP/Lat standing or AP/stress
dorsiflex films

E. Treatment
• Non-surgical
- weekly serial manipulation
and casting
- must follow certain order
of correction
- success rate 15-80%
• Surgical
- majority do well; calf and
foot is smaller
Pes Planus (flatfoot)
A.) General
- refers to loss of normal medial
long. arch
- usually caused by subtalar joint
assuming an
everted position while weight
bearing
- generally common in
neonates/toddlers

B. Evaluation
- painful
- flexible
C. Treatment
(i) Flexible/Asymptomatic
- no further work up/treatment is
necessary!
- no studies show flex flatfoot has
increased
risk for pain as an adult

(ii) rigid/painful
- must r/o tarsal coalition –
congenital fusion or
failure of seg. b/w 2 or more
tarsal bones
- usually assoc with peroneal
muscle spasm
- need AP/lat weight bearing films
of foot
metatarsus adductus/In-
Toeing
•normal hindfoot,
medially deviated
midfoot

• diagnosis made if
lateral aspect of foot
has “C” shape, rather
than straight