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.

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.

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.

CLUB-FOOT; TALIPES.

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.