Manual of Surgery Volume II Part 29

The spastic form of talipes equino-varus is comparatively rare. The plantar flexors and invertors distort the foot into the equino-varus att.i.tude. The heel is drawn up, the anterior part of the foot is adducted and inverted at the mid-tarsal joint. The muscles are tense and rigid, and the reflexes exaggerated. The condition is frequently bilateral, and is often a.s.sociated with other deformities of the lower limb and with a characteristic spastic gait. Considerable improvement may be brought about by lengthening the tendons of the shortened muscles. In severe cases it may be necessary to resect a portion of the tarsus.

The occurrence of #varus without equinus# is so exceptional as not to call for separate description.

#Pes Equinus.#--This deformity, in which the foot is in the position of plantar-flexion with the heel drawn up and the toes pointed, is nearly always acquired as a result either of poliomyelitis or of spastic paralysis. In typical cases the patient walks on the b.a.l.l.s of the toes (Fig. 145). It is seldom met with as a congenital condition.

Occasionally it is due to nerve lesions such as peripheral neuritis, or to injuries and diseases in the region of the ankle, when the foot has been allowed to remain for long periods in the att.i.tude of plantar-flexion. In a limited number of cases the equinus att.i.tude is a.s.sumed to compensate for shortening of the limb.

[Ill.u.s.tration: FIG. 145.--Bilateral Pes Equinus in a boy aet. 7, the result of Spastic Paralysis.]

In _poliomyelitis_ the deformity is most often unilateral (Fig. 146), while in _spastic paralysis_ it is frequently bilateral (Fig. 145), and is usually accompanied by excessive arching of the foot--pes cavus--as a result of plantar-flexion at the mid-tarsal joint, and hyper-extension of the first phalanges and plantar-flexion of the second and third phalanges of the toes--"clawing of the toes."

[Ill.u.s.tration: FIG. 146.--Extreme form of Pes Equinus in a girl aet. 8, the result of Anterior Poliomyelitis.]

_Clinical Features._--In the mildest cases the patient is able to bring the foot to a right angle. In average cases the heel is raised off the ground, and the foot rests on the b.a.l.l.s of the toes. In extreme cases, and especially when the extensors are completely paralysed, the toes may be flexed towards the sole, and the weight is borne on the dorsum of the foot (Fig. 146). The patient suffers from painful corns and callosities, and from inflammation of bursae which form over the points of pressure. When unilateral, the patient compensates for the lengthening of the limb by flexing the knee and throwing the limb outwards in walking. In severe cases, especially when both limbs are affected, the patient may be dependent on crutches.

The talus projects on the dorsum, the anterior part of its trochlear surface escapes from the tibio-fibular socket, and the calcaneus is drawn up so that it comes into contact with the bones of the leg (Fig.

147).

[Ill.u.s.tration: FIG. 147.--Skeleton of Foot from case of Pes Equinus due to Poliomyelitis.]

Shortening of the soft parts affects chiefly the muscles inserted into the tendo Achillis, the posterior ligament, and posterior parts of the lateral ligaments of the ankle. The fasciae, ligaments, and muscles of the sole of the foot are also shortened. The flexors of the toes, the tibialis posterior, and the peroneus longus are shortened to a less degree.

_Treatment._--Of all the deformities of the foot, pes equinus is that most easily rectified. In recent cases a great deal may be done by regular manipulations, and by the wearing of some corrective splint or apparatus between times.

In well-marked cases it is necessary to lengthen the shortened structures, and especially the tendo Achillis. When the equinus is corrected, the excessive arching of the foot (pes cavus) and the clawing of the toes usually disappear, but it may be necessary to lengthen the flexor tendons, especially that of the great toe, and also the plantar fascia.

Jones divides the tendo Achillis and the flexors of the toes subcutaneously, and maintains the dorsiflexion by excising an oval flap of skin from the front of the ankle.

In aggravated cases, the bones must be attacked, for example by excising the talus. Arthrodesis of the ankle alone or along with the mid-tarsal joint may be indicated when these joints are flail-like.

Amputation is reserved for cases which are otherwise hopeless, such as that shown in Fig. 147.

When the deformity is compensatory to shortening of the limb, it is usually said to be a mistake to correct the equinus. Experience shows, however, that in young patients growth is stimulated by walking on the limb after the deformity has been corrected; the sole of the boot is then raised to the necessary extent.

#Pes Calcaneus.#--In this deformity the foot is dorsiflexed at the ankle-joint. It is sometimes combined with eversion of the foot--_pes calcaneo-valgus_, or with inversion--_pes calcaneo-varus_.

Pes calcaneus may be congenital or acquired. In the _congenital form_ the deformity is frequently bilateral. There is dorsiflexion at the ankle-joint, and if an attempt is made to flex the foot towards the sole, the extensor tendons stand out prominently. In marked cases the long axis of the calcaneus is vertical, the tendo Achillis lies in close contact with the tibia, and the hollows on either side of the tendon are absent. The peronei are displaced from their grooves, and may lie in front of the lateral malleolus.

Corrective manipulations are commenced within a few days after birth, and a malleable splint is worn between times. When the child begins to walk there is a natural tendency towards recovery. In severe cases it may be necessary to lengthen the contracted tendons--the extensor digitorum, the extensor hallucis, and, it may be also, the peroneus tertius and tibialis anterior; the tendo Achillis may require to be shortened.

In the _acquired form_, the appearances are different, because the anterior part of the foot is usually flexed towards the sole, thus disguising to a certain extent the dorsiflexion at the ankle. This form is nearly always due to poliomyelitis, but it may also result from accidental division of the tendo Achillis. The anterior part of the foot is flexed towards the sole by the contraction of the plantar fascia and short muscles of the sole, the b.a.l.l.s of the toes are approximated to the heel, and a deep transverse groove is formed in the sole opposite the mid-tarsal joint. The deformity presents a combination of the hollow foot--pes cavus--with pes calcaneus, and resembles that of a Chinese lady's foot. The foot rests on the heel and on the b.a.l.l.s of the great and little toes, the sole of the foot being so deeply hollowed that even the lateral border does not touch the ground.

In paralysis of the calf muscles alone, the tendons of the peronei or flexor digitorum longus may be divided and st.i.tched to the calcaneus, to take the place of the tendo Achillis. If the calf muscles are not completely paralysed and the tendo Achillis is merely stretched, this tendon may be shortened by splitting it longitudinally and making the ends overlap, or its insertion may be displaced downwards. When the ankle is flail-like, it may be necessary to perform arthrodesis.

Jones gets rid of the cavus deformity by resecting a wedge with its base towards the dorsum from the middle of the tarsus; the foot is then placed in a position of extreme calcaneus, the dorsum coming into contact with the front of the leg. Four weeks later a wedge is taken from the posterior part of the talus large enough to bring the foot down to a right angle with the leg; the articular surfaces of the tibia and fibula being denuded of cartilage, ankylosis takes place in a good position.

#Pes Calcaneo-valgus.#--This deformity, which consists in a combination of dorsiflexion at the ankle and eversion of the foot, is as common as pure calcaneus (Figs. 148 and 149); the heel is depressed, the sole looks laterally, and its medial border is convex.

Although it may be congenital, it is usually acquired as a result of poliomyelitis. The calf muscles are paralysed while the peronei retain their power, and, along with the tibialis anterior and the extensors of the toes, become secondarily contracted. Treatment is conducted on the same lines as in pes calcaneus, and the valgus may be controlled by implanting the peroneus brevis into the navicular.

[Ill.u.s.tration: FIG. 148.--Pes Calcaneo-valgus with excessive arching of foot.]

[Ill.u.s.tration: FIG. 149.--Pes Calcaneo-valgus, the result of Poliomyelitis.]

#Pes Calcaneo-varus.#--In this rare deformity the heel is depressed and the sole of the foot looks inwards.

#Pes Cavus.#--In this deformity, which is known also as _hollow claw-foot_, _pes arcuatus_, or _pes excavatus_, the longitudinal arch of the foot is exaggerated as a result of the approximation of the b.a.l.l.s of the toes to the heel (Fig. 150). It is most frequently met with as an addition to pes equinus or pes calcaneus of paralytic origin, and has already been described. There is a mild form which is congenital, and which is quite independent of paralysis; another variety occurs in diseases of the spinal cord, such as Friedreich's ataxia.

The name hollow claw-foot appropriately indicates the clinical appearances. The arch is exaggerated and the instep abnormally high; there is hyper-extension of the toes at the metatarso-phalangeal joints, and plantar-flexion at the inter-phalangeal joints; the plantar fascia and muscles are shortened. The footprint shows that neither border of the foot touches the ground. The patient complains of pain in the instep, of painful corns over the heads of the metatarsal bones, and of difficulty in getting properly fitting boots.

_Treatment_ should first be directed towards the equinus or calcaneus element of the deformity, for if these are corrected the cavus condition tends to disappear. Exercises and ma.s.sage should be persevered with, and boots without heels should be worn. The contracted structures in the sole may require to be divided, either subcutaneously or by the open method, as a preliminary to forcible correction, and the hallucis tendon may be brought through the head of the first metatarsal. In aggravated cases the talus and the heads of the metatarsal bones may be excised.

FLAT-FOOT--PES PLa.n.u.s AND PES VALGUS

Flat-foot or splay-foot is that deformity in which there is loss of the arch, and the foot tends to be p.r.o.nated and abducted. The term _pes pla.n.u.s_ is applicable when there is merely loss of the arch; _pes valgus_ when the foot is p.r.o.nated and the sole looks laterally. Of all deformities of the foot, flat-foot is the one for which advice is most frequently sought; it is also a common complication of other disabilities of the foot and of the lower extremity. It is usually bilateral, and is about twice as common in the male as in the female.

Various types are met with; they are known according to their cause, as static, congenital, traumatic, paralytic, rachitic, rheumatic, arthritic, gonorrhal, and tabetic.

[Ill.u.s.tration: FIG. 150.--Pes Cavus in a.s.sociation with Pes Equinus, the result of Poliomyelitis.]

[Ill.u.s.tration: FIG. 151.--Radiogram of Foot of adult, showing the changes in the bones in Pes Cavus.]

#Static or Adolescent Flat-foot.#--This, by far the most common and important variety (Fig. 152), generally develops between the ages of fourteen and twenty. It is called static because the essential factor in its production is a disproportion between the weight of the body and the supporting power of the arch of the foot.

[Ill.u.s.tration: FIG. 152.--Adolescent Flat-foot.]

It is met with in rapidly growing children or adolescents of feeble muscular development and with long narrow feet, and those especially who, after leaving school, begin some occupation which entails much standing--such as that of a factory hand, message boy, or domestic servant. To enable him to stand with the least effort for long periods, the patient adopts an att.i.tude which makes little demand on the muscles, and throws nearly all the strain of the body weight on the ligaments and bones of the feet. This, which has been called "the att.i.tude of rest," consists in standing with the limbs apart, the knees slightly flexed, the legs slightly rotated laterally at the knee, and the feet p.r.o.nated, with the toes pointing laterally. The most important local factors predisposing to flat-foot are weakness of those muscles which normally support the ankle and the tarsal arches, especially the tibiales; weakness of the ligaments of the foot; and softness of the tarsal bones. When these conditions are present and a faulty method of standing and walking is adopted, the undue strain to which the tendons and ligaments are exposed results in their being stretched; the bones are altered in position, and flat-foot results.

The head of the talus is displaced medially, and is protruded between the calcaneus and navicular, tending to separate them from one another, stretching the inferior calcaneo-navicular ligament and causing the anterior part of the foot to be abducted. The plantar ligaments--especially the inferior calcaneo-navicular--are stretched and lengthened. In something like 80 per cent. there is the combined deformity--pes plano-valgus--in those who apply for treatment.

[Ill.u.s.tration: FIG. 153.--Flat-foot, showing loss of arch.]

_Clinical Features._--The patient complains of being easily tired, and of pain in the foot after walking or standing. There is generally more pain before the appearance of the deformity than when it has developed, and at this stage it is not so easily recognised, and is apt to be called "rheumatism." The most common seat of pain is at the medial border of the foot behind the tubercle of the navicular, and this is due to stretching of the inferior calcaneo-navicular ligament.

Pain is also complained of in the middle of the dorsum across the instep, from stretching of the interosseous ligaments. Later, there is pain over the greater process of the calcaneus in front of the lateral malleolus, from these bones coming into contact. There may be nocturnal cramp in the muscles of the leg and foot.

The faulty att.i.tude of the foot in standing and walking is usually evident. The foot appears longer and broader than normal, and when the body weight is put on it, it spreads out with the toes extended until the entire sole is in contact with the ground. In advanced cases, the medial border of the foot may be actually convex. Below and in front of the prominent medial malleolus, the head of the talus forms a rounded eminence, and a little farther forwards and lower still is the projection of the tubercle of the navicular. The eversion of the foot as a whole is best seen from behind; if the central axis of the leg is prolonged downwards, it approaches the medial border of the heel instead of pa.s.sing through its centre; or, stated differently, instead of the axis of the calcaneus being a continuation of that of the leg, it deviates laterally and the medial malleolus is abnormally prominent. When the eversion is more p.r.o.nounced, the sole looks laterally and the tendons of the peronei stand out in relief. The anterior part of the foot is displaced laterally. Flat-foot is frequently a.s.sociated with stiff great toe; the patient having lost the power of dorsiflexing the toe, the first phalanx and first metatarsal are in a straight line, instead of forming an angle open towards the dorsum.

The muscles of the leg are flabby and poorly developed. When the patient is seated and asked to move the foot in different directions, there is a characteristic stiffness, ungainliness, and restriction in the range of movement. The feet are usually cold and sweat excessively. The gait is slouching, and there is a want of spring and elasticity. The lengthening of the foot results in the tendons, especially the flexors, being too short, hence hammer-like contraction of the toes may be brought about. The boots, after being worn, show a bulging of the instep towards the sole, greater wearing away of the sole along the medial border, and, when there is stiff great toe, an absence of the transverse crease on the dorsum opposite the b.a.l.l.s of the toes. Footprints may be obtained by wetting the soles of the feet.

The print of a normal foot shows only the heel, the lateral border of the foot, and the b.a.l.l.s and tips of the toes. In flat-foot the medial border appears in the print to a greater or less extent (Fig. 154). If a record is wanted to estimate the progress of treatment, the sole of the foot is painted with a 5 per cent. solution of ferro-cyanide of pota.s.sium, and the patient stands on paper painted with the liquor of the perchloride of iron diluted one-half; the print appears dark blue on a yellow ground.

[Ill.u.s.tration: FIG. 154.--Imprint of Normal and of Flat Foot.]

_Skiagrams_ are useful for showing displacement of bones and differences between sitting and standing, and for recording the results of treatment.

_Prophylaxis of Flat-foot._--Stress is to be laid on a supervised training of the whole muscular system, and especially of that of the legs. In walking and standing, the feet should be kept parallel and not pointed outwards, as was formally taught in schools of gymnastics and insisted upon by drill instructors. Children should be taught to walk properly, rising on the b.a.l.l.s of the toes with each foot in succession. Attention should also be directed to the boots, which should be so fashioned that the medial side of the boot is kept straight and the end of the boot is opposite the big toe.

_Treatment._--This is directed towards restoring and maintaining the arch of the foot. As the measures adopted necessarily vary with the extent to which the condition has progressed, it is convenient for purposes of treatment to recognise the following four degrees. A first degree, in which the arch reappears when the weight is taken off the foot or the patient rises on the b.a.l.l.s of the toes; a second, in which the normal att.i.tude can be restored by manipulation; a third, in which this is only possible under anaesthesia; a fourth, in which the bones are so displaced and altered in shape that correction is impossible without operation.

_Cases of the First Degree._--If there is marked pain and tenderness, the patient must lie up. The general health is improved by a nourishing diet and by cod-liver oil and tonics; and the legs and feet are douched and ma.s.saged thrice daily. When pain and tenderness have disappeared, the patient is instructed how to walk and exercise the feet. In walking, the medial edges of the feet should be parallel with one another, first the heel should touch the ground and then the b.a.l.l.s of the toes. He should neither stand nor walk long enough to cause fatigue, and in standing he should alter the att.i.tude of the feet from time to time, and occasionally rise on the b.a.l.l.s of the toes. The following exercises, devised by Ellis of Gloucester, should be practised: (1) Rising on the b.a.l.l.s of the toes, the toes being directed straight forwards; (2) rising on the b.a.l.l.s of the toes, with the points of the great toes touching each other, and the heels directed out, so that the medial borders of the feet meet in front at a right angle; (3) in the same att.i.tude, after rising on to the b.a.l.l.s of the toes, the knees are flexed and then extended before the heels descend again; (4) while seated in a chair, one leg crossed over the other, circ.u.mduction movements of the foot are carried out; (5) while standing, the medial border of the foot is raised off the ground several times, then the patient walks to and fro on the lateral border of the foot, and in the same att.i.tude lifts one foot over the other.

These exercises should be carried out slowly and deliberately, with the feet bare, and they should be carefully supervised until the patient thoroughly understands what is aimed at. The movements should be performed a definite number of times at regular intervals, but should not be pushed so as to cause pain or fatigue. The patient should be fitted with well-made lacing boots, with the heel and sole raised about half an inch on the medial side so that the foot rests mainly on its lateral border. The additional leather, which can be applied by any bootmaker, is in the form of a wedge, with its base to the medial side, one on the sole and one on the heel. The wedge fades away towards the lateral border, and also forwards towards the tip. In time, the limbs are further strengthened by sea-bathing, cycling, skipping, and other exercises.

In _cases of the second degree_, the patient should be provided with a metal plate inside the boot. That known as Whitman's spring is the most popular. A plaster cast is taken of the sole while the foot is held in its proper position, and on this a metal plate, preferably of aluminium bronze, is modelled. This is covered with leather and inserted into the boot. We have found the supports devised by Scholl simple and efficient. The treatment described for cases of the first degree is carried out in addition.