I.
SKENARIO
A mother brought her 4 monthss boy in outpatient clinic. She noticed that both of her boy’s leg looks excessively turned inward since he was born. The is abnormality at other part of his body. She had normal delivery with normal weight birth. There was no history of taking medicines and illness during pregnancy. She has already brought him to a masseusure (traditional healer) but there was no improvement.
I I.
KLARIFIKASI ISTILAH 1. excessively excessively turned turned inward : tungkai tungkai memutar memutar ke dalam 2. abnorm abnormalit ality y : keadaa keadaan n abno abnorma rmall 3. norm normal al deli delive very ry : peng pengel elua uara ran/ n/pe pena nari rika kan n bayi bayi dan dan memb membra rane ne plasenta pada saat lahir secara hormonal 4. pregnancy pregnancy : keadaan keadaan mengandu mengandung ng embrio/ embrio/fetus fetus dalam dalam tubuh tubuh 5. massea masseasur suree : tukan tukang g pijat pijat tradi tradisio sional nal 6. illnes illnesss : keadaa keadaan n yang yang ditunda ditunda/pe /penyi nyimpa mpanan nan nyata nyata dari keadaan keadaan normal
I I I.
IDENTIFIKASI MASALAH 1. Anak Anak laki-lak laki-laki(4 i(4 bulan bulan), ), dengan dengan kaki kaki terlih terlihat at “exces “excessiv sively ely turne turned d inward inward”” sejak sejak ia lahir, lahir, sedang sedangkan kan anggot anggotaa badan badan yang yang lainny lainnyaa normal. 2. Dia Dia dila dilahi hirk rkan an seca secara ra norm normal al deng dengan an BB norm normal al dan dan sela selama ma kehamilan ibunya tidak ada riwayat pemakaian obat dan kelainan. 3. Dia
telah
diobati
secara
tradisionaltetapi
perbaikan/kemajuan
IV.
ANALISIS MASALAH
1. Bagaim Bagaimana ana anato anatomi mi ekstr ekstremi emitas tas inferi inferior? or?
tidak
ada
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sintesis 2. Bagaim Bagaimana ana pengar pengaruh uh riwayat riwayat pemaka pemakaian ian obat obat dan kelainan kelainan pada pada saat kehamilan? sintesis 3. Meng Mengap apaa tida tidak k ada ada peru peruba baha han n sete setela lah h diob diobat atii secar secaraa tradi tradisi sion onal al pada kasus ini? Pada kelainan Congenital Congenital Talipes Equino Equino Varus dapat dilakukan dilakukan pengobatan pengobatan antara lain melalui manipulasi (non operatif) dan operatif. Pada tindakan non operatif perlu dilakukan casting selama ± 1-2 bulan bahkan ada yang selama 3 bulan dengan tujuan untuk mengoreksi dan mempertahankan koreksi dari kelainan yang ada sehingga nantinya dapat berfungsi normal. Sedangkan pada kasus ini pasien telah diobati secara tradisional (oleh masseureuse), jadi upaya pengobatan pun pun kurang kurang efektif efektif karena karena seoran seorang g masseu masseureu reuse se memili memiliki ki kompet kompetens ensii yang yang berbeda dengan seorang dokter. 4. Apa DD kela kelaina inan n pada pada kasus kasus ini? ini? Different diagnosis dari Congenital Talipes Equino Varus adalah : •
Postural clubfoot
•
Metatarsus adductus (atau varus)
•
Celebral palsy 5. Bagaim Bagaimana ana worki working ng diagn diagnosi osiss pada kasus kasus ini? ini?
Working diagnosis pada kasus ini adalah Congenital Talipes Equino Varus
6. Peme Pemerik riksa saaa aan n penu penunj njan ang g apa apa saja saja yang yang dibu dibutu tuhk hkan an dalam dalam kasu kasuss ini? sintesis 7. Bagaimana Bagaimana gambara gambaran n klinis klinis dari dari Congenit Congenital al Talipes Talipes Equino Equino Varus? sintesis
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13. Bagaim Bagaimana ana treatm treatment ent dan penceg pencegaha ahan n kelain kelainan an pada pada kasus kasus ini? ini? sintesis 14.
Apa ko komplikasi ke kelainan pa pada ka kasus in ini? si sintesis 15. 15.
Baga Bagaim iman anaa Komp Kompet eten ensi siss dokte dokterr umum umum kela kelain inan an pada pada kasu kasuss ini? ini?
sintesis
V.
HIPOTESIS A Boy, 4 bulan menderita Congenital Talipes Equino Varus
VI.
KERANGKA KONSEP
A Boy , 4 tahun Riwayat ibu selama kehamilan: -tidak ada riwayat pemakaian obat -tidak ada penyakit
Excessively turn inward
Tidak ada kelainan lain
CTEV
Traditional healer
gagal treatment Non operatif
Manipulasi casting
gips
operatif
Rigid
Non rigid
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VII.
LEARNING ISSUES
Pokok Bahasan
a. Anato atomi
What
I What What I don` don`tt
What I have to How I will
Know
Know
prove
Tulang,otot
Morf Morfol olog ogii
Bagi Bagian an
Learn
yang yang Text Text book book
ekstremitas
pada
mengalami
bawah
ekstremitas
deformitas
dan jurnal
bawah b. b. Kela Kelain inan an
Definisi
Kongenital
Angka
Kelainan
kejadian,
kongenital kongenital yang dan jurnal
faktor faktor etiologi, etiologi, di
c. Club foot
Definisi
deri erita
diagnosis,
anak anak
penanganan
tersebut
Epidemiologi
Anak Anak
Etiologi,
tersebut
patofisiologi,
mend menderi erita ta
manifestasi
foot
klinis, diagnosis, tatalaksana, komplikasi, pencegahan
Text Text book book
oleh
lak laki-la i-lak ki
laki laki-l -lak akii Text Text book book dan jurnal club club
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VIII.
SINTESIS
ANATOMI EKSTREMITAS INFERIOR
1. Tung Tungka kaii ata atass ( pah pahaa )
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a. Tulan ulang g b. Otot
: os femu femur r : m. sartorius, sartorius, m. iliacus, iliacus, m.psoas, m.psoas, m. pectineus, pectineus, dan m.
c. quad quadric ricep epss femor femoral alis is,, m. rect rectus us femo femori ris, s, m. vast vastus us late lateral ralis is,, m.va m.vast stus us medi medial alis is,, m. vast vastud ud inte interm rmed ediu ius, s, m. gracilis d. Perdarahan : a. a. Femoral ralis
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b. Otot
: m. m.tibialis ant anterior, m. m.ekstensor di digitorum lo longus, m.peroneu m.peroneuss tertius, tertius, m.ekstenso m.ekstensorr hallucis hallucis longus, longus, m.
Pero eroneus
longus,
m.peron roneus
brevis,
m.gastrocnemius, m.soleus b. b. Perd Perdar arah ahan an : a. Tibi Tibial alis is ante anteri rior or,, caba cabang ng-c -cab aban ang g a. Pero Perone nea, a, a.tibialis posterior c. Pers Persar araf afan an
: n.pe n.pero rone neus us prof profun undu dus, s, n.pe n.pero rone neus us aupe auperf rfic icia iali lis, s, n.tibialis
ANATOMI PEDIS Tulang tulang penyusun Pedis
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•
Cal calcaneus
•
Os Naviculare
•
Os cuboideum
•
Os cuneiforme medial
•
Os cuneiforme intermesium
•
Os cuneiforme laterale
•
Os cuboideum
•
Os metatarsa (I-V)
•
Os digitorum phalanges (I-V)
•
Os phalanx proximal (I-V)
•
Os phalanx media
•
Os phalanx distalis
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Adapun sendi-sendi yang berada pada Brevis : •
A. tarsometatarsales & intermetatarsales Sendi Sendi sinovi sinovial al dengan dengan jenis jenis plana plana dan dihubun dihubungkan gkan oleh oleh ligament ligamentum um dorsalis plantaris dan interossei
•
A. metatarsophalangeal dan interphalange Dihubu Dihubungka ngkan n oleh oleh ligam ligament entum um transv transvers ersum um profun profundas dasendi endi-se -sendi ndi dan kelima jari kaki
Pedis dibagi 2 yakni plantar Pedis dan Dorsal Pedis sebagai berikut : 1. Plan Planta tarr Ped Pediis
Otot otot telapak kaki ada 4 lapisan Lapisan Lapisan 1. yakni yakni m. abducot abducotrr halluc hallucis, is, m.flex m.flexor or digito digitorum rum brevis brevis,, m.abduc m.abductor tor digit digitii minimi Lapisan 2. yakni, m.qudratus plantae, mm. lumbricales, tendo m. flexor digitorum longus, tendo m.flexor hallucis longus Lapisan 3. yakni m.flexor hallucis brevis, m.abductor hallucis, m.flexor digiti minim brevis Lapisan 4. yakni mm. interossei, tendo m.peroneus longus, tendo m.tibialis posterior 2. Dorsum Pe Pedis
Otot-otot Dorsum Pedis
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2. A. Arcuata Arcuata yang yang berjalan berjalan ke lateral lateral di bawah bawah tendo eksten ekstensor sor berhad berhadapan apan dengan basis osis metatarsi 3.
A. metata metatarsa rsalis lis dorsal dorsalis is I yang yang memper memperdar darahi ahi kedua kedua sis ibu jari jari kaki (Snell,2006)
Anatomi pada penderita CTEV
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Pender Penderits its CTEV CTEV mengal mengalami ami pemanj pemanjang angan an pada ligam ligamen en di bawaha bawaha maleol maleollus lus literalis literalis yakni ligamen ligamen calcaneofi calcaneofibulare, bulare,sehin sehingga gga sendi diantara diantara tulang-tula tulang-tulang ng tarsal tarsal tidak bisa bergerak bergerak seperti seperti seharusnya seharusnya dan tulang-tul tulang-tulang ang pedis mengalami deformitas.
Tulang tarsal yang kemungkinan mengalami mengalami deformitas akibat CTEV CTEV adalah calcaneuss, talus and navicular .
Gambaran anatomi penderita CTEV
Bentuk dari kaki sangat khas. Kaki bagian depan dan tengah inversi dan adduksi. Ibu
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terbatas. Kaki tidak dapat didorsofleksikan ke posisi netral, bila disorsofleksikan akan menyebabkan menyebabkan terjadiny terjadinyaa deformitas deformitas rocker-bottom dengan dengan posisi posisi tumit tumit equinu equinuss dan dorsofleksi pada sendi tarsometatarsal. Maleolus lateralis akan terlambat pada kalkaneus, pada plantar fleksi dan dorsofleksi dorsofleksi pergelangan pergelangan kaki tidak terjadi pergerakan pergerakan maleoulus maleoulus lateralis terlihat tipis dan terdapat penonjolan korpus talus pada bagian bawahnya. Tulang kuboid mengalami pergeseran ke medial pada bagian distal anterior tulang kalkaneus. Tulang navicularis mengalami pergeseran medial, plantar dan terlambat pada maleolus medialis, tidak terdapat celah antara maleolus medialis dengan tulang navikularis. Sudut aksis bimaleolar menurun dari normal yaitu 85° menjadi 55° karena adanya perputaran subtalar ke medial.
Terdapat ketidakseimbangan otot-otot tungkai bawah yaitu otot-otot tibialis anterior
dan posterior lebih kuat serta mengalami kontraktur sedangkan otot-otot peroneal lemah dan memanjang. Otot-otot ekstensor jari kaki normal kekuatannya tetapi otot-otot fleksor jari kaki memendek. Otot triceps surae mempunyai kekuatan yang normal.
Tulang belakang harus diperiksa untuk melihat kemungkinan adanya spina bifida.
Sendi lain seperti sendi panggul, lutut, siku dan bahu harus diperiksa untuk melihat
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•
Talipes calcaneovagus : deformitas kaki pada tumit yang terpuntir ke luar garis tengah badan dan bagian anterior kaki terangkat1
•
Talipes calcaneovarus : deformitas kaki pada tumit yang terpuntir ke arah garis tengah badan dan bagian anterior terangkat1
•
Talipes calcaneus : dorsofleksi dimana jari-jari lebih tinggi daripada tumit
•
Talipes cavovalgus : deformitas yang arkus longitudinal kakinya tinggi secara abnormal dan tumit terpuntir ke luar dari garis tengah tubuh1
•
Talipes cavovarus: deformitas yang arkus longitudinal kakinya tinggi secara abnormal dan tumit terpuntir ke dalam dari garis g aris tengah tubuh1
•
Talipes cavus : arkus longitudinal kaki yang sangat tinggi; dapat kongenital atau akibat kontraktur atau gangguan keseimbangan otot-otot
•
Talipes equinovalgus : deformitas kaki yang tumitnya terangkat dan terpuntir ke luar dari garis tengah tubuh1
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•
Talipes valgus : eversi atau membengkok ke luar; deformitas forefoot adduksi dan supinasi melalui sendi midtarsal, tumit varus pada subtalar, tumit varus pada pada subtal subtalare arequi quinus nus pada pada ankle ankle dan deviasi deviasi medial medial seluru seluruh h kaki kaki dalam dalam hubungan dengan lutut. (salter)
•
Talipes varus : inversi atau membengkok ke dalam
Club foot yang terbanyak merupakan kombinasi dari beberapa posisi dan angka kejadian yang paling tinggi adalah tipe talipes equinovarus (TEV) dimana kaki posisinya melengkung kebawah dan kedalam dengan berbagai tingkat keparahan.
Etiologi
Etio Etiolo logi gi Cong Congen enit ital al Tali Talipe pess
Equi Equino no Varu Varuss
belum samp sampai ai saat saat ini ini belum
diketa diketahui hui
pasti(unknown) tetapi diduga ada hubunganya dengan dengan : Persistence Persistence of fetal fetal positioning, positioning, Gene Genettic,
Cair airan
amnion
dal dalam
ket ketuban ban
yang
terlalu
sedikit
pad pada
wakt waktu u
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perkembanga perkembangannya. nnya. Karenanya, Karenanya, clubfoot clubfoot terjadi terjadi karena elemen disruptif disruptif (lokal maupun umum) yang menyebabkan perubahan faktor genetic (cronon). •
Teor Teorii fetu fetus, s, yakni yakni blok blok mekan mekanik ik pada pada perk perkem emba bang ngan an akiba akibatt intrauterine crowding.
•
Teori neurogenik, yakni defek primer pada jaringan neurogenik.
•
Teori amiogenik, bahwa defek primer terjadi di otot.
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Sindrom Edward, yang merupakan kelainan genetic pada kromosom nomer 18
•
Pengar Pengaruh uh luar luar sepert sepertii penekan penekanan an pada pada saat saat bayi bayi masih masih didala didalam m kandunga kandungan n dikarenakan sedikitnya cairan ketuban (oligohidramnion)
•
Dapat dijumpai bersamaan dengan kelainan bawaan yang lain seperti spina bifida
•
Penggunaan ekstasi oleh ibu saat sedang mengandung
Epidemiologi
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terseb tersebut ut akan akan menimb menimbulk ulkan an deform deformita itass dimana dimana dipenga dipengaruh ruhii pula pula oleh oleh tekanan tekanan intrauterine.
Patogenesis Dibedakan dalam 3 kelompok : o CTEV posisional : kelainan ini disebabkan keadaan posisi janin selamakehidupan intrauterine, biasanya abnormalitas bentukkaki dapat di kembalikan dengan mudah o CTEV neurologic : kelainan ini biasanya berhubungan dengan spina bifida atau artrogiposis
oCTEV idiopatik : Dal Dalam
per perkemba mbangan
embrio rio,
kaki aki
meng engalami ami
- Posisi awal, kaki ada dalam garis lurus dengan tungkai -Posisi embrio, kaki dalam posisi equinovarus aduksi -Posisi fetus, kaki dalam posisi equinovarus ringan
3
posisi sisi
berbeda eda
:
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betis, betis terlihat tipis, tumit terlihat kecil dan sulit dipalpasi. Pada manipulasi akan terasa kaki kaku, kaki depan tidak dapat diabduksikan dan dieversikan, kaki belakang tidak dapat dieversikan dari posisi varus. Kaki yang kaku ini yang membedakan dengan kaki equinovarus paralisis dan postural atau positional karena posisi intra uterin yang dapat dengan mudah dikembalikan ke posisi normal. Luas gerak sendi pergelangan kaki terbatas. Kaki tidak dapat didorsofleksikan ke posisi netral, bila disorsofleksikan akan menyebabkan menyebabkan terjadiny terjadinyaa deformitas deformitas rocker-bottom dengan dengan posisi posisi tumit tumit equinu equinuss dan dorsofleksi pada sendi tarsometatarsal. Maleolus lateralis akan terlambat pada kalkaneus, pada plantar fleksi dan dorsofleksi dorsofleksi pergelangan pergelangan kaki tidak terjadi pergerakan pergerakan maleoulus maleoulus lateralis terlihat tipis dan terdapat penonjolan korpus talus pada bagian bawahnya. Tulang
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•
Metatarsus Metatarsus adductus adductus (atau varus)- adalah deformitas pada metatarsal saja. Kaki bagian depan mengarah ke bagian medial dari tubuh. Dapat dikoreksi dengan manipulasi dan mempunyai respon terhadap serial terhadap serial casting .
•
Celebral palsy
Penegakan diagnosis Anamnesis
terdiri dari Autoanamnesa dan Alloanamnesa. 1.Sifat dari sakit / nyeri:
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Fistulae
Warna (kemerahan / kebiruan (livide) / hiperpigmentasi)
Benjol Benjolan an / pemben pembengka gkakan kan / cekuk cekukan an dengan dengan hal ± hal hal yang yang tida tidak k bias biasa, a, misalnya adanya rambut diatasnya, dst.
Posisi serta bentuk dari ekstremitas (deformitas).
Jalan pasien (gait, waktu masuk kamar periksa) 2. Feel ( Palpasi) Pada waktu ingin palpasi, terlebih dahulu posisi penderita diperbaiki agar dimulai dari dari posis posisii netra netrall / posis posisii anat anatomi omi.. Pada Pada dasa dasarny rnyaa ini ini meru merupak pakan an pemer pemerik iksaa saan n yang yang
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arah pergerakan, mulai dari titik 0 (posisi netral) atau dengan ukuran metric. Pencatatan ini penting untuk mengetahui apakah ada gangguan gerak. •
Kekak Kekakuan uan sendi sendi dise disebut but ankyl ankylosi osiss dan hal ini ini dapat dapat diseba disebabka bkan n oleh oleh fact factor or
intraarticuler atau ekstraarticuler. •
Pergerakan yang perlu dilihat adalah gerakan aktif (apabila penderita sendiri yang
mengger menggerakan akan karena karena disuruh disuruh oleh oleh pemerik pemeriksa) sa) dan gerak gerak pasif pasif (bila (bila pemerik pemeriksa sa yang yang menggerakan). Selain pencatatan pemeriksaan penting untuk mengetahui gangguan gerak, hal ini juga penting untuk melihat kemajuan / kemunduran pengobatan.
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Untuk dapat mengenal keadaan abnormal, penting mengetahui apa yang disebut ³dalam batas normal´, sehingga apabila dalam pemeriksaan diragukan normal atau tidak, pemeriksaan pemeriksaan perlu di ulang pada jangka waktu tertentu secara periodic. Hal ini disebabkan disebabkan karena definisi kelainan bawaan adalah ³kelainan bentuk dan fungsi yang didapat sejak lahir´ (Salter). Disebut orthopedic checc list, karena pemeriksaan dilakukan secara teratur dari cranial turun ke kaudal, dimulai dari kepala sampaiujing jari kaki, untuk mencari kelainan musculo musculo skeletal. (Mcglynn,1995) 1. Anamnesa:
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•
Bagian punggung, dilihat ketika pasien dibalik.
b. Feel ---Diperiksa ---Diperiksa sekaligus untuk melihat fungsi. Raba benjolan yang ada. c. Move
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1. Tulang Belakang---bayi perlu dibalik, caranya adalah dengan memegang leher bayi dari depan dan dibalik, dimana kedua anggota gerak bawah disisi radius atau ulna lengan bawah pemeriksa.
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Metata Metatarsa rsall conve converge rgence nce
40° on DP view (hindfoot varus) on DP view Slight Slight on latera laterall view view,, slig slight ht None (forefoot supination) on lateral view, on DP view
increased (forefoot supination) on DP view
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yang yang berpeng berpengala alaman man.. Deraja Derajatt beratn beratnya ya deform deformit itas as dapat dapat ringan ringan,, sedang sedang atau atau berat, berat, tergantung tergantung fleksibili fleksibilitas tas atau adanya resistensi resistensi terhadap terhadap koreksi. koreksi. CTEV harus dibedakan dibedakan dengan postural clubfoot atau posisional equinovarus dimana pada CTEV bersifat rigid,
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•
Penatalaksanaan masalah, seperti kekambuhan deformitas, supinasi kaki bagian depan dan metatarsus varus.
Manipulative stretching and stretching and retention in cast-splint
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