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Clubfoot Treatment Manual
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   Iris Lohan Treatment Of Congenital ClubfootUsing The Ponseti Method Workshop Manual[2nd Edition]   1 FOREWORD This2 nd edition of the workshop manual is primarily designed for attendees of training workshops inChina, helping them to understand what Congenital Clubfoot is, grasp the Ponseti method of Clubfoot treatment and get helpful advice. Of course I would like to see it used in lots of othercountries as well. It should serve as a reference book when questions occur and I hope it will be avery practical and helpful guide for practioneers using the Ponseti technique. I have endeavoured touse drawings to make very clear the correct hand positions for manipulation and casting.Over the years I gained more experience in the treatment and encountered challenges especially inolder children and children with other health issues associated with Clubfoot. With this 2 nd edition Iaim to improve the quality by corrections, changes and additions. I strongly recommendphysiotherapy, combined with the Ponseti management when the child starts wearing the abductionbrace.This manual provides a “Congenital Clubfoot assessment and treatment record” (Appendix 1) andalso contains Information for parents (Appendix 2)to help the parents  understand their child’s condition, the treatment, and their very important role and responsibility in the treatment. I added a“Doctor’s check up sheet ” (Appendix 3) and a “ Parent ’ s instruction sheet ”  (Appendix 4). These four appendices are designed for making copies for the use of  every child’s treatment.  I want to express my thanks to Drs Marc Sinclair and Norgrove Penny who taught the Ponsetimethod at two Clubfoot courses in Guilin, China in May 2004, where I was able to learn thismethod of treatment. I am also very thankful to Dr Jose Morcuende for your visit in Guilin inSeptember 2005, your advice and help via email, and for responding to a lot of questionsconcerning the treatment of children with Clubfoot in China.A special thank you, Xiaoyan, for your invaluable assistance in helping to teach and translate atClubfoot workshops in China, and all the translation work for the Chinese manual. You are atreasure. Karen, the idea of making drawings of the foot movements has been quite helpful for me.Thanks. Thank you, Brian and Angela, for all the corrections of my German English . Tony andAndreas, thanks a lot for your help with the arrangements of text and images on the computer.Guorong, Carolyn and Peggy, thank you for all the translation work for the 2 nd edition. Yuan, thank you so much for your corrections in the Chinese 2 nd edition. May this manual serve thousands of children with Clubfoot and their families - to change their lives forever! Iris Lohan ( 罗伊乐 )Physiotherapistiris.lohan@gmail.com REFERRENCES 1) Congenital Clubfoot, Fundamentals of treatment: Ignacio v. Ponseti, Oxford University Press2) Clubfoot: Ponseti Management: various authors, Editor: Lynn Staheli MD, Global-HELPPublication3) The Ponseti method of Clubfoot Manipulation, Workshop Manual: prepared by Shafique Pirani,MD and Norgrove Penny, MD4) Dtv-Atlas der Anatomie. Bewegungsapparat Band 1: Werner Platzer Deutscher Taschenbuchverlagund Georg Thieme Verlag5) Funktionelle Anatomie der Gelenke. Band 2. Untere Extremität: I.A. Kapandji. Ferdinand EnkeVerlag6) Treatment of Complex Idiopathic Clubfoot: Ignacio V. Ponseti, MD; Miroslav Zhivkov, MD;Naomi Davis, FRCSEd; Marc Sinclair, MD; Matthew B.Dobbs, MD; Jose A. Morcuende, MD,PhD), CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 0, pp.000-0007) Articles found at “Ponseti International Association”  (www.ponseti.info) 8) Der kleine Fuß ganz groß, Barbara Zukunft-Huber, Elsevier Urban&Fischer9) Funktionelle Anatomie des Menschen, Johannes W.Rohen, Schattauer   2 TABLE OF CONTENTS FOREWORD AND REFERRENCES ..................................................... 1 CONGENITAL CLUBFOOT AND THEPONSETI TREATMENT IN CHINA ..................................................... 3 - 4 ANATOMY AND MOVEMENTS OF THE FOOT The foot bones ............................................................................................. 5The foot segments ....................................................................................... 6The movements of the foot .......................................................................... 7 - 8 KINEMATIC COUPLING OF MID FOOT AND HEEL ...................... 9 PATHOANATOMY OF CONGENITAL CLUBFOOT ......................... 10 - 11 ASSESSMENT, EXAMINATIONS, SCORING Assessment, examination, check up and documentation .............................. 12Pirani severity scoring ................................................................................. 14Pirani scoring signs ..................................................................................... 15 - 17 PONSETI TREATMENT Overview of CF treatment using the Ponseti method (basic guideline) ............ 18Early CF treatment start using the Ponseti method ( guideline ”young er child“ ) . 19   Later CF treatment start using the Ponseti method (guideline ”older child” ) ....... 20Manipulation ............................................................................................... 21 - 22Hand positions for manipulation ................................................................. 23 - 24Casts after manipulations ............................................................................ 25 - 27Hand positions for casting ........................................................................... 28 - 30Casts removal .............................................................................................. 31Percutaneous tenotomy of the Achilles tendon ............................................ 32 - 33The bracing ................................................................................................. 34 - 36 RECURRENCES AND THEIR MANAGEMENT ................................. 37 - 39 COMMON ERRORS TO AVOID ........................................................... 40 THE PARENTS ........................................................................................ 41 APPENDICES:Please copy and use appendices 1- 4Appendix 1:Congenital Clubfoot assessment and treatment record ..... 42 - 43 Appendix 2:Information for parents ....................................................... 44 - 48 Appendix 3:Doctor`s check up sheet ...................................................... 49 Appendix 4:Parent ’ s instruction sheet .................................................... 50 Appendix 5:  Atypical Clubfoot   .................................................................. 51 - 53 Appendix 6: Congenital CF associated with other defects and after surgery 54 Appendix 7: Links relating to the Ponseti method; treatment examples....... 55   3 CONGENITAL CLUBFOOTAND THE PONSETI TREATMENTIN CHINA   1. Information about Congenital Clubfoot    Congenital Clubfoot is Clubfoot present at birth.      Clubfoot is one of the most common congenital deformities. About 1 in every 1000 children is born with clubfoot worldwide.    Congenital Clubfoot is a developmental deformation: A normal developing foot turns into a Clubfoot around the 3 rd month of foetal life. Etiologicalfactors for the development of the deformity seem to be active for several years explainingrelapses after correction. The aetiology is not exactly known, but is believed that genetic andextrinsic factors are involved. Fibrosis, meaning a pathological increase of connective tissue,seems to be the main reason leading to the deformity. At the posterior and medial aspects of Clubfeet, shorter muscles and increased tissue in muscles, fasciae, ligaments, tendons andtendon sheaths had been found.    Hereditary   transmission: One parent affected by Congenital Clubfoot: about 3-4% chance to transmit to the child.Both parents affected by Congenital Clubfoot: about 15% chance to transmit to the child.      More in boys than in girls    Bilateral (both feet) or unilateral (one foot)    Alone or in association with neuromuscular diseases, chromosomal abnormalities,syndromes and other congenital abnormalities like:Arthrogryposis Multiplex Congenita (AMC), Myelomeningocele (MMC),Larsen Syndrome, Diastrophic Dysplasia, Moebius Syndrome, Amniotic Band Syndrome,Metatarsus Adductus, Limb deformities like Syndactyly, missing toes, extra toes.For details see Appendix 6. 2. Why use the Ponseti method for Clubfoot treatment in China?    Clubfoot children are often abandoned or face a future in poverty.By correcting their feet, they get the opportunity to live a normal life.    The Ponseti method is a very effective and relatively inexpensive treatment with good longterm results.    Medical workers of a lower level can learn the manipulation and casting technique as well asorthopaedic surgeons.    Surgeons report that Clubfeet treated by surgical methods become weak, stiff and are oftenpainful in adult life.
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