The principles and practice of modern surgery

by Roswell Park

1. Congenital Club-foot; Talipes Equinovarus.

—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.