It is important to impress this on parents, teachers, nurses, dressmakers, and all who have a part in the care of the young, in order that they may realize the importance of ensuring symmetrical growth and of preventing the right-hand habit. It is to be expected that after deformity has occurred there may result a series of perversions of function in nerves, as well as in viscera; thus, respiration and circulation may be interfered with, the liver may be compressed, while, of course, autopsy will show all sorts of distortion of bone, among other pathological changes.
—Too often the condition is regarded as so trivial that it is likely to be outgrown, or else is quite disregarded, or, on the other hand, occasionally it is regarded as one of gravely serious import and maltreated or overtreated on this account. In the majority of instances scoliosis is a self-limited condition, whose limit may be reached at variable stages of deformity in different individuals. In slight cases any serious illness may cause such muscular weakness as to permit of serious increase of distortion. Therefore, the patient’s general condition is to be taken into account just as much as the shape of the back.
—If one may be permitted a Hibernicism, the proper treatment for scoliosis is prevention. This may be made to include the earliest possible recognition of trifling deviations from the normal. It should be made to include, in general, supervision of school desks and the way in which children work at them, as well as of children’s games and exercises, in which it should be made a point that they be taught to make as much use of one hand as of the other. It should include also supervision of children’s methods of seating themselves at the piano or at the sewing table, as well as the posture which they assume during sleep, while they should be taught to stand and walk properly and to avoid a too early use of corsets. Active treatment should consist, first, of correction of bad postural and other habits by methods as vigorous as are military drill and discipline. Patients tire easily after such exercise, and sufficient rest should be taken, the patient lying symmetrically upon the back. There is usually opportunity with young children for great ingenuity in devising suitable exercises without making them too irksome. They should be taught to play games at least as much with the left hand as with the right. Gymnastic exercises, especially those with dumb-bells, will be found effective, and it is advisable to have a heavier dumb-bell in the left hand than in the right. The more severe cases should be handled with great care in order not to overdo that which should be done. Each case should be studied by itself, which means that such cases should not be taught in classes. Roth calls that “the key-note position” which is closest to the normal that the individual can voluntarily and comfortably assume. From this as a basis the surgeon should work up. Perhaps as much can be done without apparatus as with it, particularly if will power is concentrated on the effort. This is harder with the young, but pride may sometimes be appealed to as a substitute for volition. As strength is gained more strenuous gymnastics may be prescribed, including suspension from rings or the simple horizontal bar, while much heavier dumb-bells may be used, as taught by Teschner.
Mechanical corrective treatment is directed mainly to stretching shortened ligaments and contracted muscles. For this purpose many forms of apparatus have been devised. Their principal benefit lies in increasing backward flexibility at the point where curvature is most pronounced. As a substitute for such apparatus, and in private houses, padded stretchers or lounges may be supplied on which patients may lie either quietly or during massage. Finally the matter of corrective corsets and braces remains to be considered. External support takes away from the muscles and ligaments their functions and work. Nevertheless in some cases this is necessary. No appliance of this kind that may be supplied should be continuously worn. It should be removed for work and exercise, as well as for toilet purposes. Recumbency in bed is much better than too vigorous bracing. Only in old, neglected, or peculiar cases should it be considered necessary to resort to much external aid.
The relaxation and debility of old age permit of such deformities as rounded and stooped shoulders, certain degrees of kyphosis, and sometimes even pronounced stooping and deformity, whose merely senile causes are more or less combined with rheumatoid arthritis of the vertebral and costovertebral joints. These features are accompanied by more or less pain or difficulty in locomotion. Many instances of ischias scoliotica, referred to in the preceding section, would find a place among these clinical pictures. Postmortem there are found exostoses, synostoses, or ankyloses sufficient to account for the deformity. Rickets also causes skeletal deformities, in which nearly all the bones may participate, the spine rarely totally escaping. In such cases various typical and atypical deformities may be met.
Paralytics may show various curvatures, as do also subjects of pseudomuscular hypertrophy and syringomyelia. Lordosis is seen in pregnancy and in congenital hip dislocation, where it is purely compensatory in each instance and does not outlast its real cause. In fact it may be encountered as a compensatory feature of any other kind of spinal curvature.
A still more marked condition of chronic ostitic changes is seen in spondylitis deformans, which differs little from arthritis deformans of other joints, save that in these cases it usually spares the joints of the extremities. It has been known as a rare sequel of gonorrhea, even in the young. Osteophytic outgrowths occur frequently and fuse together, causing ankyloses and sometimes great deformity, even to the extent of making the spine assume a right angle with the extended limbs. Considerable pain is frequently experienced during the course of these very slow changes. The entire spine becomes more or less rigid, consequently there is little or no angular prominence, while the ribs become immobilized as well. For this condition there is little or no treatment of any avail. Sometimes paralysis supervenes and the condition is not infrequently fatal.
Acute osteomyelitis of the vertebræ is occasionally noted. It occurs nearly always in young and growing children, and is most common in the lumbar spine. It is essentially the same here as occurring in the long bones or their joint ends, and has been described in the previous chapter. Its symptoms may be severe, and it is not infrequently followed by abscess. When such abscesses point posteriorly they may be recognized and incised. When, however, pus takes the anterior path it will probably escape detection, at least until too late. The prognosis is often unfavorable.
This name was proposed by Gibney for what seems to be an infectious periostitis involving the vertebral column, of a character similar to that which has been described in a previous chapter. It is characterized by excessive pain, tenderness, and later stiffness. It may occur during or after mild as well as severe cases of typhoid.
Kümmel has shown that a traumatic and non-tuberculous ostitis of the vertebræ occurs, with succeeding kyphosis resembling that of Pott’s disease, but not so angular, usually without associated abscesses, but with occasional paralyses. This may occur without necessary reference to that curvature which may follow a healed or healing spinal curvature. Inasmuch as the condition occurs only after the lapse of considerable time after injury, it is questionable whether it represents any distinct form of disease.
Malignant disease of the spine may assume a type either of sarcoma when primary or carcinoma when secondary. The latter type is much the more common, and is not so infrequent as an expression of metastasis from cancer in various other parts of the body, even the more distant. It is most common in the lower spinal region. Pain occurs early and is usually severe. It is as often referred as localized. It may lead to curvature of the spine with some of the grosser signs of spinal caries, but the prominence, if any occurs, will be rounded rather than angular. When paralyses occur they usually assume that type described by Charcot as paraplegia dolorosa. (See Plate XXXVIII.)
When symptoms of a general type like those produced by spinal caries occur in adults who are known to have had previous or present malignant disease the inference will be that they are to be interpreted as local expressions of the same character. Under these circumstances treatment can only be palliative. There is no hope of cure.
The term spondylolisthesis implies a partial displacement forward of the body of the last lower or next to the last lower lumbar vertebra, usually the former, which slips forward on top of the sacrum with very little perceptible displacement of arches. The condition may be slight or well marked, and may or may not be followed by secondary changes. There appears to be a real fragmentation or separation of the body from the arch, which may be traumatic, congenital, pathological, or the sole result of pressure from above; later exostoses or osteophytes appear about the separation, thus forming a new fixation and preventing further displacement.
The condition is more common in females and in the young, and most cases give a traumatic history. In those which do, deformity may follow accident or it may be long postponed, perhaps until pregnancy.
—The lesion is recognized by certain alterations of gait, with a sharp lumbar lordosis and unduly prominent buttocks and iliac crests, so that these patients much resemble those having congenital hip dislocation, the pubes being higher and the sacrum lower than the normal, this diminution of pelvic obliquity being practically always pathognomonic. On vaginal or rectal examination undue prominence may be felt above the sacrum. Some of these cases complain of much pain, either local or referred, down the limb, the same being made worse by exercise.
PLATE XXXVIII
Sarcoma of the Spine and Cord. (Goldthwait.)
—Diagnosis should be made as between this condition, Pott’s disease, double congenital dislocation of the hip, and rickets.
—The condition does not admit of extended treatment, save that a certain proportion of cases are benefited by such fixation as is afforded by a plaster jacket, which firmly encloses the pelvis and supports the lower part of the trunk upon it.
The plane of the terminal articular surface of the lower end of the femur is not at right angles with the axis of its shaft; in other words, the inner condyle is placed a little lower or beyond the location of the outer. In this way sufficient angular arrangement of the leg upon the thigh is permitted so that, with the upper ends of the femora separated by the width of the pelvis, the knees and the ankles may, under normal circumstances, be made to touch when the limbs are fully extended. Thus a slight degree of angular deflection at the knee is normal. When this is exaggerated to a degree not permitting the ankles to touch when the knees are in contact the condition is known as genu valgum, or knock-knee. When, on the other hand, the angle is lessened or reversed so that the knees are more or less separated when the ankles are in contact the condition is then known as genu varum, or bow-leg. These two conditions constitute the typical and classical types of knock-knee and bow-leg. Other conditions, however, which lead to the same result occur through various and irregular curvatures or irregularities of the femur or the tibia, or both, and there thus may be produced atypical yet most pronounced instances of these same deformities. These deformities may be apparent almost from birth, may appear during early childhood, or not until adolescence. As a rule they are not manifested until young children are learning to walk. Whenever they appear before this time they are expressions of infantile rickets, which should be recognized as such and corrected by mere manipulation while the bones are still flexible, the correction being maintained, and by suitably feeding and medicating the patient. (See the general subject of Rickets.)
Fig. 261
Rachitic changes in limbs. (Lexer.)
In fact rickets supplies the explanation for the great majority of these deformities; incomplete ossification and calcification of the bones accounting for the comparative ease with which they yield to pressure or other deforming influences. Rickety children always manifest a tendency to defective ossification at epiphyseal lines, and it is here that the change usually takes place. Nevertheless marked instances of curvature are seen in all the bones of the lower extremity. As deformity in any given direction becomes more pronounced the tendency to its exaggeration becomes greater. Finally these changes involve not only the bones proper but the ligaments and the other joint structures, which yield where pressure is abnormal and greatest, thus completely changing their shape and internal relations. Along with other changes in knock-knee there is a tendency to external rotation, perhaps even to spiral curvature of the tibia; the patella lies outside of its normal position, the tendons are more or less displaced, while, at the same time, there may be inflection of the feet as an effort at compensation (Fig. 261).
With the exception of spinal curvatures and torticollis there is perhaps no more conspicuous deformity than that produced by these abnormalities at the knee-joint. While at first gait is not seriously affected, it is in time, especially in cases of double knock-knee. When these knees are bent to a right angle the angular deformity disappears and all that remains is the rotation of the tibia. Hence it follows that all correction of these deformities, either slow or operative, should be applied to the fully extended leg. In advanced cases there is frequently a complication with flat-foot, which may or may not be painful. The condition is rarely produced by paralytic affections, and should be differentiated from mere atrophy of wasted and contracted legs. A form of knock-knee is occasionally seen in the adult, which is of traumatic origin and is due to improper care or neglect in the treatment of the injury.
—The treatment of this condition is either mechanical or operative. Mechanical treatment varies between the gentlest expedients and the use of more or less extensive and cumbersome apparatus. When a young and growing child begins to show evidence of either of these deformities it is usually sufficient to supply shoes which are reasonably stiff, and raise one or other border of the sole and heel, according as we wish to influence the growth of the limb, i. e., in knock-knee the inner border of the foot is to be raised, in bow-leg the outer. The consequence of even slight influence thus constantly maintained when the child is upon its feet is usually sufficient to rectify slight degrees of these deformities. When, however, the case is pronounced more radical measures should be applied. Massage has been recommended along with manipulation, but should be gently performed. The different forms of apparatus in use afford various methods of making pressure against that condyle which is too prominent. It is possible to make them efficient, but only when they are both well planned and well made in the first place and intelligently applied and watched. The special forms of apparatus sold in the instrument stores are of little value. Too often it happens that when efficient they cannot be tolerated, and that when tolerated they are inefficient. Much speedier and more satisfactory results are achieved by operative methods, so that, in general, they may be regarded as the more desirable.
Operative treatment consists in some modification either of osteoclasis or osteotomy.
Osteoclasis has to do with the forcible stretching, bending, or even breaking of those parts which show the greatest effects of the deformity or are known to be its primary seat. In young children with tender and still somewhat flexible bones this may be accomplished by the hands alone, the patient being under an anesthetic. Manual power failing a simple instrument known as the osteoclast, which affords a means of applying powerful pressure by the agency of a screw at just the desired point, is used. Pressure is then applied and carried to the necessary degree, even with partial or complete fracture of the bone at fault. In this way is inflicted a simple fracture which permits of the immediate redressing of the limb, with such overcorrection of the deformity as seems desirable. The limb thus treated is completely encased in a suitable plaster-of-Paris splint, and should be held in the desired position until the plaster is completely hardened and not likely to yield. Osteoclasis, though it often appears an exceedingly barbarous procedure, is one of the most beneficent when properly managed, and is rarely followed by an undesirable result.
Osteotomy is performed by the use of the chisel and mallet, the former being introduced through a small incision made in the skin, passed down to the bone with its cutting edge parallel to the bone axis until the bone itself is reached, after which it is turned at right angles to it and the mallet used until the chisel has been driven partly or completely through the shaft of the bone or the portion which it is intended to attack. The chisel should be partly withdrawn and its position changed if it is necessary to continue its use. Thus by a partial division of the bones of the young it is possible usually to so weaken them that, without undue force, and by manual power, they are fractured at the desired point. The operation should be done with the most complete aseptic protection. The procedure recommended by Macewen is now universally accepted. The incision is made at the inner side of the thigh just above the tubercle for the adductor magnus, and the osteotome (as the chisel especially made for this purpose is called) is passed through it, down to the bone, turned at right angles, and made to cut nearly through the shaft. Lest it become too firmly wedged it may be moved a little laterally after each blow of the hammer. The operation, if properly done, is practically bloodless; the small opening made for the chisel is sealed at the moment of its withdrawal, the deformity corrected with the least amount of handling or disturbance, and the plaster-of-Paris bandage immediately applied, with the leg in exactly the position which it is desired should be maintained. Such a dressing may be left for three or four weeks before being changed. One change is usually sufficient, and in from six to seven weeks the patient is allowed to slowly regain use of the member.
A special set of osteotomes, after Macewen’s pattern, is furnished by the instrument dealers for those who practise osteotomy. It consists of a set of three straight chisels, consecutively numbered, the first being a little thicker and the third the thinnest of the three, and thus made with the intent to use the thickest first in order that in the notch made by it the thinner instruments can be subsequently more easily manipulated.
Bow-legs are nearly always of rachitic origin, occurring with less angular deformity, and as the result of the warping or bending of bones which are not sufficiently rigid to sustain the weight they are made to carry. Most cases of bow-legs have their origin within the very early years of childhood. Other cases are seen in infancy and before children have ever borne much weight upon their feet. The deformity must be accounted for by muscle tonus, mere muscle activity serving to place enough stress upon the bones to swerve them from their normal axes. The bones probably bend outward because the muscles on the inner side are the stronger. Children thus affected walk not so much with a limp as with a waddle, with the feet rather apart, and some inversion of the toes. Double and complicated curves occur in many of these cases, both femurs and tibias participating, and having an anterior as well as a lateral bowing. Such complications materially increase the difficulty of any treatment.
—The treatment of bow-leg is generally considered simpler than that of knock-knee. Occurring in young and growing children it can be overcome, if taken early, by the expedient already mentioned, elevating the outer border of the sole of each shoe. The more mechanical and the purely operative methods of treatment are essentially the same as those just described for knock-knee, based on similar but reversed principles. In the very young manual force will often serve the purpose of a more formal osteoclasis, but the osteoclast may be used whenever it seems indicated. In those cases where the bowing is due to abrupt and almost angular deformity, osteotomy is indicated. This is made on exactly the same principles as mentioned above. In all instances spiral curvatures should be overcome so far as possible during the process of forcible correction and dressing in the plaster-of-Paris bandages ordinarily used. Here, as previously, all treatment should be addressed to the limbs in their fully extended position. If the rings of the ordinary osteoclast be sufficiently padded and protection afforded in this way, the skin rarely sloughs, and the damage, which is, at least, theoretically done to the tissues, is quickly repaired. Failure in union after any of these operations is exceedingly rare.
In general the term talipes is applied to any malformations of the foot by which it is more or less misshaped and its function impaired. The commonest of these is that known and described below as talipes equinovarus. Of these various deformities there are four principal types, according as the foot is inverted, everted, hyperflexed, or hyperextended. More particularly they are:
These forms may be variously blended, as well as seen in varying degrees from the slightest possible deviation to the most pronounced form. Statistics show that about one child in every five hundred is born with some form of club-foot.
Club-foot may be either of acquired or congenital origin. Acquired club-foot is essentially always of paralytic nature, following usually infantile paralysis or those injuries by which nerves have been divided or caught in callus or in tumors. As the result of such loss of nerve or muscle power, in certain muscle groups, malpositions of the feet are caused which simulate those of congenital origin.
—This consists anatomically in an inward dislocation at the metatarsal joint of the anterior part of the foot, in consequence of which the relations of all of the other component parts of the foot are deranged; the scaphoid is swerved on to the inner and lower side of the astragalus to such an extent as to touch the internal malleolus; the cuneiforms follow the scaphoid and the metatarsals follow the cuneiforms; the cuboid is shifted to the inner side and does not articulate squarely with the calcis. In infants these bones are cartilaginous, but as the individuals grow and these miniature bones develop and ossify they take similar and abnormal shapes and positions. The calcis is drawn into a more vertical position than normal by drawing up the heel, and is even somewhat rotated on its own vertical axis; thus its anterior articulating surface is made to look obliquely inward. This displacement of bones causes dislocation of tendons, the anterior group being drawn mostly to the inner side. The patient walks more and more on the outside of the foot, and as he does this adventitious bursæ develop on the outer border, which become very thick and form in time large callosities. In the most pronounced cases there occurs, in connection with all this, curvature or spiral inward rotation of the tibia, and even of the femur of the affected limb, while the contracted muscles become overdeveloped and those which are disused underdeveloped (Fig. 262).
Fig. 262
Talipes equinovarus.
Among the causes of club-foot heredity seems to play a considerable part, as it often happens that two or three club-footed children are born of one mother. The deformity has been ascribed to abnormal or exaggerated posture in utero, with compression. This theory is at least attractive and has the force of argument from antiquity, for Hippocrates thus believed. Unquestionably the normal intra-uterine position of the fetus includes a certain degree of equinovarus. Yet if this were the real cause the condition would occur apparently much more frequently. It has been ascribed also to disparity in strength between opposing groups of muscles, that group which causes the deformity being naturally the stronger, it being at the same time unimportant whether one group is relatively too strong or the other relatively too weak. Most monstrosities or seriously defective infants have also club-foot, from which some argue that the central nervous system has something to do with it; yet it has been shown in over 1200 cases of club-foot that only twice did such defect of the central nervous system as spina bifida occur. The embryologists and comparative anatomists regard it as an expression of arrested development, while evolutionists consider it an atavistic reversion to an earlier anthropoid arrangement. None of these theories really satisfactorily explains the deformity. Therefore we should hold that either there are different and variable causes or that we have not yet found the true one.
Treatment of Congenital Club-foot.
—There being in these cases no tendency to spontaneous improvement, mechanical or operative treatment, or both, are required. If these be afforded early the prospects of restoration, practically to the normal, are good, but treatment should be begun early and conducted with great care and patience. It is not so difficult to correct the deformity, but correctional supports should be worn for a relatively long time, while the older the case the more difficult become all the features, both mechanical and durational. Parents are often eager at first, but later become inattentive or careless. The main objects are to be attained by correction of position by force or by division of contracted or shortened tissues, or retention in position, with the addition of any other features which may influence growth and development according to normal standards. Of these we will speak first of rectification: (a) bloodless, as by purely mechanical force, or by means of certain apparatus, and (b) operative, as by subcutaneous tenotomy, aponeurotomy, etc., or by open incision, through which are performed osteotomy, excision, astragalectomy, tarsectomy, etc., as the operator may see fit.
In all of these the anterior part of the foot is to be forced outward as well as raised, two distinct features, which should be combined but not confused.
In the young infant gentle force applied many times a day, with the persuasion of a strip of adhesive plaster, applied beneath the foot and over its outer border, and spirally upward to the inside of the leg, can be made effective in mild cases; but overstretching of the tendo Achillis is a necessary part of this maneuver every time it is practised. The more positive method consists of fixation of the foot in overcorrected position within a plaster or starch bandage, the same extending above the knee, which should be slightly flexed, the dressing to be renewed every two or three weeks, and correction increased until it has become overcorrection.
In well-marked and in resistive cases an anesthetic should be given, while by the use of sufficient force, which may be relatively great, but which should be gently applied, the resisting tissues are so stretched, if necessary to the point of something yielding, that but slight pressure is required to hold the foot in an overcorrected position. When the knife is required the tendo Achillis should always, and the plantar tendons and fasciæ usually, be subcutaneously divided, under aseptic precautions. The foot is then enveloped in suitable dressings and put up in overcorrected position for two or three days, in a rigid dressing at first of starch, but after this in plaster of Paris; this is the writer’s plan of procedure. The insertion of the point of the tenotome sufficiently deep to divide all resistive ligaments and tissues (e. g., the astragaloscaphoid or the calcaneocuboid) nowise complicates this method, but makes it more efficient.
Cases which are resistant are best submitted at once to open operation (that is, after vigorous stretching of the contracted tissues), always under strict asepsis. After decades of milder ineffectual methods it remained for A. M. Phelps, of New York, to show the benefits of this method by which all contracted tissues on the concave aspect of the foot are exposed and divided. Incision is made here from the top of the inner malleolus to the inside of the first tarsometatarsal joint. With a little care the artery can be avoided, but I have never seen any harm come from its division. Everything which proves resistant is divided, even the inner osseous ligaments. Sometimes the incisions can be made in wedge-shape, or obliquely, so that the wound does not remain so widely open. No attempt is made to close this wound. The operation may be done bloodlessly, under the Martin rubber bandage, but whether this be used or not any vessel which can be recognized as such should be tied; otherwise the wound is snugly packed with gauze (upon which I like to use Peru balsam). An ample surgical dressing is applied over it. This is covered with gutta-percha tissue, to prevent too free access of air to the blood which will ooze into the dressing, and the whole is then covered with a starch bandage, in overcorrected position; this is left, according to circumstances, for from three days to a week—the longer the better. Then everything is removed, fresh gauze placed in the wound, which will be found already largely filled up; fresh dressings are applied, and the foot put up in plaster of Paris, with or without a fenestrum or any provision by which the region of the wound may be easily uncovered for necessary renewal of dressing.
It is in the most pronounced types of cases only, with marked bone deformity, or those in which previous operations have failed, that the still more radical division or removal of some part of the tarsus is necessary. As to this no universal rule can be applied save this: take out sufficient to correct deformity. In some cases it will be sufficient to excise the astragalus (astragalectomy). In other cases it is better to remove a wedge-shaped piece of the tarsus, without reference to the name of the bones attacked (tarsectomy). I have never found it necessary to touch the external malleolus, though this has been suggested, nor to do osteotomy of the calcis or of the leg bones above the ankle, as a few have done.
Fig. 263
Park’s club foot brace.
These operations are usually practised, after a preliminary stretching, through a curved incision on the outer aspect of the foot, through which, at the same time, the thickened bursæ may be removed, or the callosities included in the incision. The chief convexity of the incision should be over the os calcis at its anterior portion. As the dissection is made the tendons are drawn aside and spared. If it be necessary to divide one or more of them it should be re-united later. According to the density of the structures a strong knife may be used, and strong scissors, or an osteotome manipulated either by hand or with the hammer. After sufficient V-shaped or wedge-shaped bone has been removed the defect should be held together, if practicable, by buried tendon sutures or wire; it is rarely necessary to use drainage. The external wound may be loosely closed with buried sutures, a suitable dressing applied, and the foot put up in a rigid splint; this should permit of removal, or at least inspection of the wound after a few days, for renewal of those dressings which are saturated with blood and for application of new dressings. After this the foot and leg should be put up in overcorrected position in plaster of Paris.
In aggravated cases of club-foot Wilson believes combined operation to give better functional results than can be obtained by any other method. The astragaloscaphoid joint is exposed by an incision over the prominence of the scaphoid, and, being cleared, is opened with chisel or bone forceps, while sufficient of the articular surfaces is removed to destroy them as such and to take out a sufficiently large wedge-shaped piece from either bone so that the desired arch of the foot is restored, or even exaggerated. Then the tendon of the extensor proprius hallucis is exposed and divided just above the great toe, the upper end of the tendon being drawn out through the first incision. To this end is attached a strong silk ligature. The scaphoid is then perforated with a bone drill at some distance from its superficial aspect and at such an angle, with the foot in correct position, that the canal thus made shall be in line with the action of the tendon. The drill is then withdrawn and the tendon passed through the opening by means of its attached silk. One inch beyond the bony canal the tendon is cut off and split in halves, each half being turned in opposite direction and fastened to the periosteum of the scaphoid with fine silk, while the foot is held in overcorrected position, so that the tendon is sewed in its new place under moderate tension. The foot is then dressed in this overcorrected position in plaster of Paris, the splint extending nearly to the knee, and the wound area being exposed by a fenestrum cut in the splint before it is hard.
The location of the incision over the dorsum or outer aspect of the foot may be varied to suit the needs of the case and the method of the attack. In a general way a flap of soft tissues is raised and tendons, so far as possible, are held outward. This is usually practicable, and it is rarely necessary to divide the latter. After operation of any type and recovery from the same it will be necessary for a long time to have the patient wear a corrective appliance. This should be applied as early as possible, and should be worn continuously, i. e., night and day; inasmuch as growth is continuous there should also be continued correctional influences. Many types of apparatus have been devised. That which the writer has found effective and has adopted for a number of years is illustrated in Fig. 263. It may be made single or double, as occasion requires. A part of the appliance is a spiral spring and a provision for a constant outward pressure is made upon the foot, by which inversion is more easily overcome, as well as any inward spiral twist of the bones of the leg. No such apparatus can be made effective unless connected suitably with a waist-band. This is, therefore, included in the shoe shown in Fig. 263. Furthermore the appliance should be so made as to permit adjustment commensurate with the rapid growth of the patient, and in order that it need not be too often renewed. Some degree of mechanical ability is required for its application and management. The principles are, however, easily mastered and most parents can soon learn to manage it.
—This condition is known also as talipes planus, or, more briefly, pes planus, the common names being flat-foot, splay-foot, or pronated foot. A particularly painful variety has been often spoken of as pes planus dolorosus.
This type of deformity is rarely of congenital origin. It is characterized by abduction and pronation of the foot, on whose inner border there often appear two prominences, one the head of the astragalus the other the head of the scaphoid. The bones show much less alteration in actual shape than in club-foot. The scaphoid is deflected somewhat to the outer side and the astragalus turned a little outward and downward. A prominent feature is that the arch of the foot is more or less obliterated, while its inner border becomes convex instead of remaining concave. This is due in large measure to relaxation of the ligaments binding the foot to the calcis, especially that extending from the astragalus (Fig. 264).
Etiology.
—The common cause of the condition is lack of sufficient strength of the parts to carry the weight of the superimposed body. It is produced often by ill-fitting shoes, accompanied by excessive strain or rapid growth and gain in weight. It is sometimes complicated by a certain shortening of the gastrocnemius (Shaffer), which prevents flexion to its complete degree and compels some degree of eversion of the foot in completing a step. In some instances it is induced by previous morbid conditions, such as rickets, paralysis, diseases of the spinal cord, and postgonorrheal arthritis. Ill-fitting footwear is the most common cause, as it compresses the front part of the foot and prevents adaptation of the foot to the position it should assume when the weight of the body is thrown upon it. The effect of this weight is to necessitate a greater divergence of the toes than such shoes permit and gradually causes the patient to walk on the inside of the foot. Flat-foot is seldom seen in those who habitually go barefooted.
The condition is best relieved by making a graphic record of each case. This is done by making the barefooted patient step first on smoked glass or on wet dusted paper, and then upon a piece of plain paper. If such a print be compared with the print similarly obtained from the normal foot it will be seen how different are the points of contact and how differently distributed is the body weight. A non-graphic but sufficient inspection may be afforded by having the patient stand upon a stool whose top is made of glass and by using a mirror beneath the feet. In any event it will be shown that the inner border of the foot is at least nearly straight or even convex, whereas it should be neither.
Fig. 264
Talipes valgus.
There are tender points over the astragaloscaphoid joints, at the base of the first and fifth metatarsals, in front of the internal malleolus, as well as often beneath the heel. Patients who thus suffer find that the feet perspire very easily. In walking the feet are everted, and when tenderness is very great it is because too much weight is borne on the inner borders of such everted feet. Inspection of the shoes will also show wearing of the inner border and over the inner malleolus.
Spontaneous cure of such cases does not occur, except perhaps after long confinement in bed from other causes, but patients occasionally become tolerant after a time, though many of them grow steadily worse and avoid using the feet more than is absolutely necessary.
Treatment.
—Mild cases will be benefited, often practically cured, by simply raising the inner border of the sole and heel of the shoe. This causes more weight to be borne on the outer border than in the natural attitude of the foot. It will be sufficient usually to make from ³⁄₈ inch to ⁵⁄₈ inch difference in the level between the inner and the outer borders of the sole and heel. Shoes may be so constructed that this difference is made invisible, or suitably bevelled narrow strips of leather may be sewed beneath the sole along the inner side, or laid in between its upper and lower layers.
While this suffices for the milder cases it is not sufficient for the more severe cases, which require forcible correction, and often under an anesthetic. The best way to accomplish this, after having patients thoroughly relaxed with chloroform, is to make a thorough manipulation of the foot, trying especially to so loosen its outer ligaments that it may be more easily put in proper position and finally overcorrected. The foot is then put up in plaster of Paris in this much overcorrected position. Such splints are worn for five or six weeks, after which suitable shoes should be provided, either with their inner borders elevated or with metal flat-foot plates inserted, or both. These plates are now in general use, and may be procured from instrument dealers and in shoe stores. In particular cases it is advisable to make a mold of the lower aspect of each foot, to have this cast in iron, and then over the iron model to have a suitable metal plate hammered so that it shall exactly fit the individual for whom it is intended.
Only in extreme cases, rebellious to other treatment, has it been shown necessary to resort to such treatment as division, by osteotomy, of the neck of the calcis or of the astragalus.
Most of these cases may be benefited subsequently by gymnastics and massage, i. e., by stretching the contracted gastrocnemius, if necessary, with some mechanical device, and improving the general condition of the leg muscles by suitable massage.
—Under this name has been described a peculiar painful affection of the third and fourth or the fourth and fifth toes, which gives rise to constant sensitiveness and sometimes attacks of acute pain, especially when the foot is shod, and which is often only relieved by immediately removing the boot or shoe. These affection’s are more common in the upper walks of society, especially among women who are disposed to cramp their feet in shoes which are too small for them. Aside from the location of the pain there will often be found a tender spot at the point of greatest complaint. As these cases become worse pain radiates farther and farther up the leg, and may even assume the type of a sciatica.
Fig. 265
Talipes equinus.
Careful inspection usually reveals either a mild degree of flat-foot, or of distortion by which the anterior part of the foot is broadened and held in a depressed position—or else the dorsal part of the foot is depressed behind the anterior part; there is also usually limitation of dorsal flexion of the foot and plantar flexion of the toes.
Morton, who first described the affection as having a peculiar type of its own, thought it due to entanglement of the external plantar nerve between the heads of the fourth and fifth metatarsal bones, and recommended for its relief excision of the head of the fourth of these. The etiology of the affection is not always apparent, but it is sometimes due to what has been described as a non-deforming type of club-foot, while in practically all other instances it is in some way connected with the use of badly fitting footwear.
Treatment.
—Without proper treatment it does not subside. A really weak and pronated foot should be supported with a proper plate and elevation of its inner border, while a short gastrocnemius should be stretched. Only in extreme cases or when these milder measures have failed need resort be had to Morton’s suggestion and excise the head of the fourth metatarsal.
—In this condition the equinus position is simulated, and the patient walks upon the anterior part of the foot only, perhaps even upon the ends of the metatarsal bones. While the congenital form is extremely uncommon the acquired form is that which commonly occurs. Appearing thus in all possible degrees it may in mild cases cause merely a slight limp, while the extreme cases cause a pronounced deformity and alteration in gait. The actual condition is one of shortening of the tendo Achillis through contraction of its component muscles, with corresponding change in shape of the bones of the foot. There is also more or less shortening of the plantar aponeurosis, and depression of the astragalus, which is drawn down upon the calcis (Fig. 265).
Causes.
—Perhaps the most common cause is paralysis, either of infantile or cerebral and spastic type, of the anterior muscles of the leg, the condition being simulated sometimes in hysteria. The spasm which follows disease of the ankle-joint may also produce it. It may be the result of muscle contraction after fractures or even after certain fevers, the foot dropping naturally into this position and remaining there altogether too long. Hence may be seen the necessity for putting the foot in the right-angle position whenever the lower limb is dressed in plaster or other rigid dressings after fracture. Talipes equinus may also be due to injury to and loss of power in the anterior muscles of the leg, or it may be compensatory, as when one leg is longer than the other. In any of these events the body weight is borne on the ball of the foot, and some degree of arching of the foot, which may be excessive, is sure to occur.
Treatment.
—In the milder cases, when seen early, it may be sufficient to thoroughly and repeatedly stretch the sural muscles, but, in the more severe forms, tenotomy of the tendo Achillis, with subcutaneous or perhaps open division of the plantar structures, will be needed. In paralytic cases tendon grafting (q. v.) will be required, probably with one or more of the measures mentioned above. In some instances nerve grafting might be profitably employed. After recovery from operation, braces adapted to each particular case will in all probability be required, at least for a time.
—In this deformity the anterior part of the foot is drawn upward by its anterior flexors and a little to the outer side, while the sural muscles are relaxed; thus the patient walks upon the heel. The condition is often more or less combined with talipes valgus. It is rarely of congenital origin, but is generally due to paralysis of the distal muscles following injury or poliomyelitis. It is sometimes of hysterical origin, and it may occur as the result of muscle spasm following bone or joint disease (Fig. 266).