Those forms due to infantile paralysis are to be treated mainly by tendon grafting or some similar expedient, and this to be followed by a suitable shoe containing a sole plate with an upright attachment and a joint opposite the ankle. Other forms must be treated, each on its own merits, but according to general principles already enunciated.

Pes Cavus.

—Here the anterior part of the foot is drawn backward and the plantar arch made much more prominent. It may even be converted into a Gothic arch. Extremes of this type are seen in the feet of Chinese women. One form is due to contraction of the peroneus longus, owing to paralysis of the sural muscles, by which the long flexors are permitted to work to extra advantage; and yet another form is often of congenital origin, having its explanation in paralysis of the interossei and other small intrinsic muscles of the foot (Fig. 267).

When an ordinary metal sole plate fails to give relief a subcutaneous or open division of the contracted structures may be practised.

CONGENITAL MISPLACEMENT (DISLOCATION) OF THE HIP.

Perhaps a more proper name for this congenital deformity would be “misplacement” rather than dislocation. It is seen much oftener in females than in males. It may be either unilateral or bilateral. The displacement is usually upward and backward upon the dorsum of the ilium. In rarer instances it is anterior and sometimes the head of the femur lies not far away from the anterior superior spine of the ilium.

Regarding its cause absolutely nothing is known. It represents defective development rather than arrest, and is a condition of intra-uterine life. The acetabulum is usually found incomplete, but whether this is the cause of the misplacement or whether it fails to develop because of the absence of the head of the femur from this cavity it is not easy to decide. The influence of heredity in these cases is undeniable, for it is known to have prevailed in certain families. Thirty years ago but little was known in regard to the affection, and nothing could be done to atone for it. Of late years it has been the subject of special study by numerous investigators (Figs. 268 and 269).

Pathological changes are noted in the capsule itself, as well as in the bony components of the joint. Thus the capsule is usually elongated and stretched out of shape, while its lower portion may be adherent to the margin of the acetabulum or may be shut off into a small cavity by itself, this cavity having but a small connection with the balance of the capsule and affording irresistible obstacles to reduction. With changed joint relations the muscular arrangements are also changed, some being lengthened, others shortened, as would naturally follow from the approximation or separation of their points of origin and insertion. Conspicuous change is seen in the upper end of the femur, which is often atrophied, while the neck is shorter than normal, its angle lessened, and the head of the bone often altered in shape. A secondary acetabulum is in time formed and is usually found upon the side of the ilium. This is shallow and insufficient to ensure firm support for the head of the femur, even were this well developed. Aside from these changes the pelvis is usually poorly developed on the affected side, its inclination increased, the sacrum forced forward and downward, the pelvic outlet widened, while a considerable degree of lumbar lordosis is present (Fig. 270).

The condition is rarely noted until a growing infant begins to learn to walk. The condition is one which has no symptoms, only signs, and these do not at first attract attention. Sometimes it will have been noted that there is an abnormality about the hip, with too free play, or a snapping sound about the joint. When the condition is unilateral there is a marked limp which increases with the age of the child. With each step the femoral head is pushed upward on the side of the ilium, and, in consequence, the pelvis is tilted toward the outside, as well as twisted downward and forward. The limb being thus actually shortened, the limp or waddling gait is easily accounted for. Along with it there is usually flattening of the tibia, while the trochanter may be felt and often seen on a level considerably above that where it properly belongs. Motility in the joint is abnormally free, and with a child on its back, by alternately pulling and pushing, the abnormally free play of the upper end of the femur may be easily demonstrated, either with the limb in its extended or the flexed position.

When the misplacement is bilateral the individual is more symmetrically deformed. The lordosis is increased, the abdomen protrudes, the thighs are separated more widely than is normal, leaving perhaps a considerable space in the perineum; the gait is of a peculiar waddling character, which makes locomotion apparently difficult, although it is free from pain. In these cases abnormal mobility of the hip may be demonstrated on each side.

As these patients grow through adolescence into maturity they sometimes improve, but usually suffer more and more difficulty in locomotion, while the abdominal protrusion and the lordosis become more and more pronounced.

Three varieties of congenital misplacement are described as backward, upward, and forward. It is in those instances where the head of the bone rests well back or well forward upon the ilium that the gait is most pronounced, but in all instances the great trochanter will be found above Nélaton’s line.

Diagnosis.

—The diagnosis offers few difficulties. The peculiar waddling gait may be seen in extreme cases of bow-legs, but then the hip-joints will be normal. Extreme lordosis may be seen in cases of lumbar spinal caries, but here again the hip-joints will be normal, while the spinal muscles will be rigid and the patient disinclined to walk. Traumatic dislocations and the results of hip-joint disease will be indicated by a history to correspond, as will also early acute joint affections following the exanthems. The diagnosis is to be made principally from coxa vara, considered below, and the various defects following infantile palsy. In coxa vara there is no corresponding abnormality of motion, while in the paralytic cases there will often be failure in muscle power, which is not present in cases of congenital misplacement. Finally in instances which offer difficulties the Röntgen rays now afford a method of diagnosis.

Treatment.

—For a long time after this condition was recognized its treatment was unsatisfactory, and it was not until Hoffa, about fifteen years ago, advanced his operative method of relief that surgeons felt at all like advising operation in well-marked cases. Then came Paci and Lorenz, first with improvements on the Hoffa operation, and then with a method of so-called “bloodless” reposition, which has been under severe test and testimony. Last of all come Bradford and Sherman with their improved methods of operation, which seem to me the most promising of all as well as the most scientific.

Lorenz was doubtless correct when he stated that the principal obstruction to reduction is the narrowed part of the capsule, just at the upper part of the acetabulum, and that if this could be torn here sufficiently to permit the passage of the head, reduction could be accomplished by manipulation alone, and maintained if the acetabulum were sufficiently deep. An almost insuperable difficulty in most cases is, however, this narrowed capsule, and the number of accidents, including not only fractures of the femur and the pelvis, but various other injuries which have resulted from too great violence, is altogether too large and too disturbing to justify the use of such force as has often been used. Of more than one hundred children upon whom Lorenz operated when making a tour through the United States, but little over 10 per cent. have given anything like ideal results; while the danger from fracture and laceration of muscles and nerves, as well as of bloodvessels, is fully as great as that pertaining to any open operation. It may therefore be maintained that the percentage of success from the use of manual force without incision does not justify the risks of the method. Sherman argues that if we may open a knee-joint without hesitation to take out a small piece of cartilage, we need not fear to open a hip-joint in order to clear away a small obstacle. The patient is thereby saved from many dangers and exposed to so few that it seems more humane and desirable in every respect.

Sherman’s method is to make traction upon the limb, drawing the femoral head down to a point just below the anterior superior crest, where it can easily be felt, and to here make an incision over it in the direction of muscular fibers so that they are not divided. After division of the capsule the head of the bone is exposed and retractors substituted by long loops of suture, put in on either side of the opening in the capsules. In many cases a tenotomy of the adductor tendons close to the pubis will also be of advantage. The leg is next released from traction and the head of the bone allowed to glide upward, while the finger is slipped into the capsule and down toward the acetabulum. Upon this finger as a guide a long, straight, probe-pointed bistoury is passed, and with it the narrower portion of the capsule is cut through, down to the bone, taking care to not cut off the ileopsoas tendon. The incision must be large enough to give free access to the acetabulum. Traction is then again made with sufficient manipulation so that the femoral head may be forced into its proper cavity. When the head is in the acetabulum the retracting sutures are tied together so as to close the upper part of the capsule, and other sutures are introduced, as needed, to close the wound, leaving space for a cigarette drain. The limb is then put into a position of abduction of from 50 to 90 degrees, rotated in or not, as needed, and a comprehensive plaster-of-Paris spica applied. In this both limbs or only one may be included. The drain should be removed in two days and the dressing left otherwise undisturbed for three months.

Bradford has added somewhat to our methods by showing not only the arrangement of the capsule, but the fact that the acetabulum is often filled with dense fibrous tissue which sometimes obliterates it, and that this tissue can be curetted out, but that if it could be utilized to aid in retaining the reduced head of the femur it would be a great benefit. He operates as follows: The hip is subjected to preliminary forcible stretching of all soft parts which can be stretched by manual or mechanical force. A posterior incision is then made, which, without dividing muscles, permits free opening into the capsule and affords a channel to the deepest portion of the acetabulum. The posterior wall of the capsule is then split, after which all constricting and other obstacles at any point are carefully divided. These may be detected by the finger, and can also be seen by a small electric light passed down inside of a sterilized glass test tube. The capsular wound is then retracted by deep retaining silk sutures, placed at the lower rim of the acetabulum, thus affording a pathway for the reduction of the head. After this has been accomplished as described above, the sutures are tied closely around the femoral neck, and these retain it in position. The other portions of the split capsule are then sewed around the head and neck, to the trochanter and fascia, in such a way as to retain the bone where it has been placed.[37]

The earlier the operation is done the better. It is necessary to always maintain the limb in a position of well-marked abduction, and for a long time, nor can patients be released from this at the expiration of the first dressing period, usually twelve to fifteen weeks, although the abduction can usually be reduced with each dressing until at last the limbs are permitted to come together after the expiration of nine to eighteen months. Even after the lapse of this length of time it may be necessary to provide some form of apparatus by which too much rotation in either direction may be prevented, or by which pressure may still be made over the trochanter, in order that it may be kept constantly pushed into the acetabulum (Figs. 271 and 272).

COXA VARA AND VALGA.

This term is applied to an abnormality in the shape of the neck of the femur, consisting of a downward curvature or bending of the femoral neck, which is thus displaced until it stands almost at a right angle with the shaft instead of at the normal obtuse angle. At the same time there is often posterior curvature, or sometimes an anterior curve, of the neck, which causes a corresponding rotation of the axis of the whole limb. The pelvic side of the hip-joint is unaffected, the change occurring usually solely in the upper end of the femur, the joint not being involved. It may appear in congenital form and then may be attributed either to intra-uterine pressure or to antenatal rickets or osteomalacia. The acquired form is usually due to a non-inflammatory softening, or to structural changes which permit of yielding, as above described. Doubtless different cases have different causes, and they are not to be included in one brief sentence. The condition corresponds to those abnormalities at the knee which produce knock-knee and bow-leg. Were the bone as easily examined at the upper end of the femur as at the knee the condition would be more easily recognized. Therefore the term has reference not so much to the results of active disease as to deformities of congenital or acquired character. Fully three-fourths of the cases are met with in male subjects, and the majority of these occur only on one side. Thus of 190 quoted by Whitman, 85 were unilateral, while only 26 occurred in females.

The more nearly the angle of fixation of the neck of the femur approaches a right angle the further above Nélaton’s line will the trochanter appear, and the more conspicuous this change the greater the difficulty in abduction. Moreover, to shortening may be added internal or external rotation, with consequent tilting of the pelvis and compensatory alteration of the spinal curves.

The disease is by no means often of traumatic origin, although traumatisms may produce an arthritis deformans, even in juvenile cases, and that this may simulate a non-symptomatic coxa valga is now well established (Fig. 273).

Symptoms.

—Coxa vara produces certain symptoms, among them pain in the joint, radiating down the front and inside of the thigh. If the deformity be very marked, joint function is impaired. Tenderness is rarely present. When pain or tenderness occur they may lead to the mistaken diagnosis of rheumatism or neuralgia. The condition may arise as the result of an acute ostitis, in which case patients will be confined to bed for some time. Actual shortening may vary from one to one and a half inches, while the limb will be found adducted, the gluteal region flattened, with a deep curve between the trochanter and the gluteal muscles.

Diagnosis.

—The diagnosis is to be made mainly between this condition and hip-joint disease or misplacement. When abnormalities in the shape or position of the limbs in the young occur in a comparatively short time, coxa vara may be suspected, especially in the absence of that disability which coxitis usually produces. The patient should be examined in both the upright and horizontal position. Coxa vara may have an abrupt onset, but it never produces abscess. It is practically self-limited and will be followed, sooner or later, by spontaneous cessation of all acute features, while coxitis is progressive, with a destructive tendency. In coxa vara we do not have the starting pains nor muscle spasms of coxitis, while the actual shortening is much more marked. In doubtful cases the cathode rays may be employed and will often greatly facilitate diagnosis. The condition may be bilateral, but will still fail to show the muscle atrophy so significant of tuberculous disease.

As between coxa vara and that senile form of coxitis already described in the chapter on Joints as arthritis deformans, it should be remembered that the latter is a disease of advanced life, while the former occurs rather in its earlier periods. Moreover, in the former there is no tendency to change in the femorocervical angle, no matter what changes may occur in other respects about the joint. When in the senile disease shortening really occurs it results from actual absorption of bone.

Coxa vara tends usually to spontaneous cessation, which may be considered recovery. Acute symptoms after a time subside, and function is regained to the full extent permitted by whatever changes have occurred in the shape of the bone. If symptoms are at all severe they demand physiological rest in bed, with traction, and the limb should not be used until pain has entirely subsided. Conspicuous deformity may call for correction by subcutaneous osteotomy made just below the trochanter. Only in exceedingly serious cases is exsection of the joint necessary.

DEFORMITIES CAUSED BY INFANTILE PALSIES.

Deformities induced by more or less acute affections of the cord and brain, or by hemorrhages, have assumed an ever-increasing importance in orthopedic work. Most of them resolve themselves into those due to acute anterior poliomyelitis and those due to cerebral hemorrhages.

Anterior Poliomyelitis.

—Anterior poliomyelitis is an acute inflammation manifested especially in the gray matter of the anterior cornua of the spinal cord, involving both the neuroglia and the cells, producing atrophy of the same and consequent paralysis of muscles supplied by the motor nerves. It may assume an acute febrile type, with rapid onset of paralysis, or it may be of slower development. Usually conceded to be of infectious origin, it still lacks the minute explanation for many of its attendant phenomena. It may appear with acute symptoms, febrile and convulsive, paralysis appearing more or less promptly. With the subsidence of other serious symptoms this paralysis remains. There may then be a period of partial improvement in the muscular condition, with disappearance of some of the most pronounced phenomena. Finally with the growth and development of the child more expressions of damage remain, and produce various distortions and deformities, varying with the muscle groups affected. Not only do deformities result, but there is more or less arrest of development, with disproportion in size between the limbs involved and those which have been spared. It is the early paralytic features which may permit diagnosis to be made in the early days of the acute febrile attack.

Cerebral Palsies.

—The cerebral palsies, so called, are the result of hemorrhages or acute disorganization of the brain. The former are usually unilateral and give rise to a corresponding hemiplegia, with either paralysis or spastic rigidity, and usually with atrophy. The paralysis may not be complete, but is rather of the paretic type, involving the entire limb, the reflexes being increased and the muscles stiffened rather than flaccid, with loss of electrical reactions.

A paraplegia points rather to lesion in the spinal cord and hemorrhage than to cerebral lesion. Transverse myelitis is rare in children. Multiple neuritis may produce somewhat similar effects, as may also the toxic paralyses due either to drugs (especially lead or arsenic) or that following diphtheria, in which case it is the muscles of the throat and neck which are likely to be involved. Figs. 274 and 275 portray extreme types which are rare, but instances of minor degree of affection are frequent.

Treatment.

—As two cases of this kind are seldom alike, treatment should be planned to meet the indications. Massage, electricity, hot-air baths, and similar non-operative measures find here a large field of usefulness, but, save in the milder cases, are insufficient. In no class of cases do tendon grafting and nerve grafting find a wider range of applicability, while tenotomy, myotomy, aponeurotomy, and occasionally osteotomy will permit of atonement for deformity which has not been treated. These operative measures have been considered.