Manual of Surgery Volume II Part 30

In _cases of the third degree_, the deformity is corrected under an anaesthetic. The foot is forcibly moved in all directions so as to stretch the shortened ligaments and to break down adhesions, it is then rotated into an extreme varus position, and fixed in plaster-of-Paris or to a Dupuytren's splint. It may be necessary to have recourse to the Thomas' wrench, employed in the correction of club-foot. When the reaction consequent upon this procedure has subsided, the question of shortening or of reinforcing the tendons concerned in the support of the arch of the foot may be considered; one of the peronei, for example, may be attached to the tubercle of the navicular. We have not found it necessary to employ this procedure.

In _cases of the fourth degree_, in which the displacement and alterations in shape of the bones const.i.tute an insuperable bar to correction, operative treatment may be considered, either resection of a wedge including the talo-navicular joint or forward displacement of the tuberosity of the calcaneus.

#Spasmodic Flat-foot.#--There are cases of flat-foot in which pain and spasm of the peronei muscles are the predominant features. If the spasm is not allayed by rest in bed and hot fomentations, the foot should be inverted under an anaesthetic; and in this position it is encased in plaster-of-Paris. Jones resects an inch of each of the peroneal tendons about 2-1/2 inches above the tip of the lateral malleolus; Armour and Dunn claim to have obtained better results from crushing the peroneal nerve in the substance of the peroneus longus.

#Paralytic Flat-foot# (Fig. 155).--In typical cases this results from poliomyelitis affecting the tibial muscles. When other groups of muscles are affected at the same time, compound deformities, such as pes calcaneo-valgus, are more likely to result.

[Ill.u.s.tration: FIG. 155.--Bilateral Pes Valgus and Hallux Valgus in a girl aet. 15, the result of Anterior Poliomyelitis.]

In paralytic valgus the medial border of the foot is depressed and convex towards the sole, and although the foot can readily be restored to the normal position by manipulation, it at once resumes the valgus att.i.tude. The leg is wasted, the skin is cold and livid, and the ankle is flail-like. The treatment consists in reinforcing the paralysed tibial muscles by attaching the peronei, or a strip of the tendo Achillis, to the scaphoid, or in bringing about an ankylosis of the joints above and in front of the talus.

#Traumatic flat-foot# is that form which results directly from injury.

It is most often due to a fall from a height on to the feet; the ligaments supporting the arch are ruptured, and the bones are displaced, either at the time of the injury or later when the patient gets out of bed. The arch can only be restored by a wedge-resection of the tarsus. Loss of the arch may follow as a result of walking on the everted foot after injuries about the ankle, especially a badly united Pott's fracture; the foot may be displaced laterally and p.r.o.nated, the sole looking laterally. This variety is very unsightly and disabling; it is treated by supra-malleolar osteotomy of the tibia and fibula.

#Other Forms of Flat-foot.#--Flat-foot is sometimes met with in rickety children, in a.s.sociation with knock-knee or curvature of the bones of the leg, and is treated on the same lines as other rickety deformities. It may follow upon an attack of acute rheumatism or upon diseases in the region of the ankle and tarsus, such as gonorrha, arthritis deformans, tuberculosis, and Charcot's disease; the gonorrhal flat-foot is extremely resistant to treatment. There is a congenital form in which the sole is convex and the dorsum concave, the result of the persistence of an abnormal att.i.tude of the ftus _in utero_. Lastly, there is a racial variety, chiefly met with in the negro and in Jews, which is inherited and developmental, and which, although unsightly, is rarely a cause of disability.

#Pes Transverso-pla.n.u.s.#--Lange describes under this head a sinking or flattening of the anterior arch formed by the heads of the metatarsal bones, of which normally only the heads of the first and fifth rest on the ground. In this condition all may be on the same level or the arch is actually convex towards the sole. It may coexist along with the common form of flat-foot, or it may be a.s.sociated with the neuralgic pain known as metatarsalgia.

#Painful Affections of the Heel.#--These include inflammation of the bursa between the posterior aspect of the calcaneus and the lower end of the tendo Achillis, inflammation of the tendon itself and its sheath of cellular tissue, and the presence of a spur of bone projecting from the plantar aspect of the tuberosity of the calcaneus.

The spur of bone is the source of considerable pain on standing and walking, and tenderness is elicited on making pressure on the plantar aspect of the heel; it is well demonstrated by the X-rays (Fig. 156).

The condition is usually bilateral. Complete relief is obtained by removing the spur by operation.

Sever of Boston calls attention to a painful condition of the heel met with in children, and a.s.sociated with changes in the epiphysial junction, allied to those met with in the epiphysis of the tubercle of the tibia in Schlatter's disease. The changes in the epiphysial junction can be demonstrated in skiagrams. Treatment is conducted on the same lines as in teno-synovitis of the tendo Achillis.

#Metatarsalgia.#--This affection, which was first described by Morton of Philadelphia (1876), is a neuralgia on the area of the anterior metatarsal arch, specially located in the region of the heads of the third and fourth metatarsal bones. It is most often met with in adults between thirty and forty, is commoner in women than in men, and is often combined with flat-foot. The patient complains of a dull aching or of intense cramp-like pain in the anterior part of the foot. The pain is usually relieved by rest and by taking off the boot. It may be excited by pressing the heads of the metatarsals together or by grasping the fourth metatarso-phalangeal joint between the finger and thumb. In advanced cases the pain may be so severe as to cripple the patient, so that she is obliged to use a crutch. On examination, the sole may be found to be broadened across the b.a.l.l.s of the toes, and there may be corns over the heads of the third and fourth metatarsals.

Skiagrams may show a downward displacement of the head of one or other of these bones, and prints of the foot may show an increased area of contact in the region of the b.a.l.l.s of the toes. The affection is of insidious development, and is usually ascribed to sinking of the transverse arch of the foot--pes transverso-pla.n.u.s--the result of weakness or of wearing badly fitting boots. The intense pain is believed to be due to stretching of, or pressure upon, the interdigital nerves or the communicating branch between the medial and lateral plantar nerves; Whitman believes it is due to abnormal side pressure on the depressed articulations.

[Ill.u.s.tration: FIG. 156.--Radiogram of Spur on under aspect of Calcaneus.]

_Treatment._--Great improvement usually results from treating coexisting flat-foot, and pain is relieved by rest, ma.s.sage, and douching. A tight bandage or strip of plaster applied round the instep before putting on the stocking may relieve pain. Boots should be made from a plaster cast of the foot, high and narrow at the instep so as to compress the bases of the metatarsals, and with the medial edge of the sole and heel slightly raised; a support may be worn in the sole, like that used for flat-foot, with both the longitudinal and transverse arches exaggerated. Scholl has devised a support for the anterior arch which we have used with benefit. When the head of one of the metatarsals is displaced, it may be removed through a dorsal incision running parallel with the tendon of the long extensor.

#Hallux Valgus and Bunion.#--_Hallux valgus_ is that deformity in which the great toe deviates towards the middle line of the foot and comes to lie on the top of, or beneath, the second toe (Figs. 155, 157). The head of the first metatarsal projects on the medial border of the foot, and, as a result of the pressure of the boot, an advent.i.tious bursa is formed, which, when thickened by chronic inflammation, const.i.tutes a prominent swelling or _bunion_. It is a common affection in civilised and especially in urban communities, and reaches its acme of development in adult women. It may occur on one or on both sides, and is sometimes a.s.sociated with flat-foot.

[Ill.u.s.tration: FIG. 157.--Radiogram of Hallux Valgus. The sesamoid bone is seen displaced towards middle line of the foot.]

The deformity develops slowly, and is usually attributed to the wearing of stockings which are unduly tight at the toes, and of improperly made boots. The boot that favours the occurrence of hallux valgus is one which is too short and has pointed toes, with the apex in the middle line of the foot instead of being in line with the great toe. The pressure of the boot displaces the great toe into the valgus position, especially if a high heel is worn, as the toes are then driven forward into the apex of the boot. Once the great toe is abducted by the pressure of the boot, the deformity is increased by bearing unduly on the medial side of the ball of the great toe, and by pointing the foot outwards in walking.

Arthritis deformans is rarely the cause of hallux valgus, but the changes characteristic of that affection are commonly present in the joint of the great toe. In p.r.o.nounced cases, the base of the first phalanx is displaced on to the lateral aspect of the head of the first metatarsal, the exposed head of which frequently shows fibrillation and wearing away of the cartilage, and is often surrounded by new bone, sometimes amounting to an exostosis. There are also fringes from the synovial membrane that may be caught between the articular surfaces. The distal end of the first metatarsal is displaced medially, broadening the tread of the foot, and in severe cases its shaft is rotated on its long axis, so that its dorsal surface looks medially; the great toe is then similarly rotated (Fig. 157). The flexor and extensor tendons and the sesamoid bones are displaced laterally. The ligaments and other soft parts on the medial side are elongated, while those on the lateral side are contracted.

In women, the chief complaint may be of the disfigurement of the boot; in others, of pain and disability resulting from the sensitiveness of the joint and of the enlarged bursa over the head of the first metatarsal. The inflamed bursa, which sometimes communicates with the joint, may suppurate, and the infection may spread to the joint.

The _treatment_ varies with the severity of the deformity. In mild cases, a great deal can be done by wearing properly made boots and stockings with a separate compartment for the great toe, or a pad of cotton wool or tent of rubber between the great and second toes. The patient should practise manipulations and exercises of the toes and feet, and putting the foot to the ground properly in walking. In p.r.o.nounced cases, the pain and tenderness must first be got rid of by rest and soothing applications. At night, the att.i.tude of the toe may be corrected by a moulded splint fixed to the medial aspect of the foot by strips of plaster; the toe is then bandaged to the distal end of the splint. Scholl has devised a prop, made of rubber, to be worn between the great and second toes. If there is flat-foot, this must receive appropriate treatment.

In aggravated cases, the deformity can only be corrected by an operation which consists in resecting the head of the metatarsal bone, and the tendon of the long extensor may be detached from its insertion and secured to the medial side of the first phalanx. A bar may be placed across the sole just behind the b.a.l.l.s of the toes, and the boot should also comply with the anatomical shape of the foot.

#Hallux Varus or Pigeon-toe# (Fig. 158).--In this deformity, which is extremely rare, the great toe deviates from the middle line of the foot; it occurs chiefly in children in conjunction with other deformities, and interferes with the wearing of boots. Treatment consists in straightening the toe and retaining it in position by a splint or plaster of Paris. The medial collateral ligament and the tendon of the abductor hallucis may require to be divided.

[Ill.u.s.tration: FIG. 158.--Radiogram of Hallux Varus or Pigeon-toe.]

#Hallux Rigidus and Hallux Flexus# (Fig. 159).--These terms indicate two stages of an affection of the metatarso-phalangeal joint of the great toe, first described by Davies Colley. In the earlier stage--_hallux rigidus_--the toe is stiff and incapable of being dorsiflexed, although plantar-flexion is, as a rule, but little restricted. When the joint, in addition to being stiff, is painful, sensitive, and swollen, the term _hallux dolorosus_ is applied.

[Ill.u.s.tration: FIG. 159.--Hallux Rigidus and Flexus in a boy aet. 17.

There is a suppurating corn over the head of the first metatarsal bone.]

As the disease progresses, the toe is drawn towards the sole and becomes permanently flexed--_hallux flexus_--and any attempt at dorsiflexion is attended with pain.

The condition is met with chiefly in adolescent males, is nearly always a.s.sociated with flat-foot, and is then usually bilateral. The patient's gait, in addition to having the characteristic features a.s.sociated with flat-foot, is peculiarly wooden and inelastic, as instead of rising on the b.a.l.l.s of the toes with each step, he puts down and lifts the sole as if it were a rigid plate. The pain is increased by walking. The boot tends to become worn away at the point of the toes and at the posterior edge of the heel, and the usual crease across the dorsum is absent.

On dissection it is found, especially in hallux flexus, that the inferior portions of the collateral ligaments are contracted, and that the cartilage of that part of the head of the metatarsal which is exposed on the dorsum is converted into fibrous tissue; there may also be other changes characteristic of arthritis deformans. Bony ankylosis has not been observed.

_Treatment._--In early cases, great benefit results from measures directed towards the cure of the accompanying flat-foot, and especially the wearing of the support of the anterior arch devised by Scholl. If the joint of the big toe is painful and sensitive, absolute rest should be enforced until these symptoms have disappeared. The patient must wear a properly shaped boot with a pliable sole, and be instructed how to manipulate and exercise the toe. Later, when the toe is already rigid or flexed towards the sole, the above treatment is not feasible. It is then best to correct the deformity either by wrenching the toe into the dorsiflexed position, under anaesthesia, and fixing it with a plaster-of-Paris bandage; or, when this is impossible, by excising the articular end of the metatarsal bone and interposing a layer of fatty or bursal tissue between the distal end of the metatarsal and the base of the first phalanx. When these measures are impracticable, the suffering may be relieved by inserting in the boot a rigid metal plate which will prevent any attempt at dorsiflexion in walking.

#Hammer-toe.#--This is a flexion-contracture which generally involves the second, but sometimes also other toes. It may be congenital and inherited, but usually develops about p.u.b.erty, and is then, as a rule, bilateral, and often a.s.sociated with flat-foot.

The first phalanx is dorsiflexed, and the second is plantar-flexed, while the third varies in its att.i.tude, sometimes being in line with the second (Fig. 160), sometimes even more plantar-flexed, and sometimes dorsiflexed. When the second toe alone is affected, as is commonly the case, it is partly buried by those on either side of it, only the knuckle of the first inter-phalangeal joint projecting above the level of the other toes (Fig. 160). The skin over the head of the first phalanx being pressed upon by the boot usually presents a corn, under which a bursa forms (Fig. 161). Both the corn and the bursa are subject to attacks of inflammation, which cause suffering and disability in walking. The soft parts at the distal extremity of the toe are flattened out by contact with the sole of the boot--hence the supposed resemblance to the head of a hammer.

[Ill.u.s.tration: FIG. 160.--Hammer-toe.]

On dissection, it is found that the contracture is maintained by shortening of the plantar portions of the collateral ligaments of the first inter-phalangeal joint and of the glenoid ligament upon which the head of the first phalanx rests.

Hammer-toe is usually ascribed to the use of tight socks and of ill-fitting boots, especially those which are median-pointed and are too short for the feet, but in some persons there appears to be an inherited predisposition to the deformity.

[Ill.u.s.tration: FIG. 161.--Section of Hammer-toe.

_a_, Corn.

_b_, Bursa over first inter-phalangeal joint.]

While corrective manipulations, strapping, and the use of splints may be of service in slight cases, it is usually necessary to perform an operation in order to extend the toe permanently. Before operating, any infective condition, such as a suppurating corn or bursa, must be corrected. The collateral and glenoid ligaments are divided subcutaneously--Spitzy also divides the flexor tendons and capsule--and if the toe can then be straightened, the foot is secured to a metal splint moulded to the sole and provided with longitudinal slots opposite the intervals on either side of the toe affected. The toe is drawn down to the splint by pa.s.sing a loop of cotton or elastic bandage round the toe and through the slots. In many cases the contraction of all the tissues on the plantar aspect, including the skin, prevents the toe being straightened even after division of the ligaments, and it is then necessary to remove the head and neck of the first phalanx through a lateral incision. This is more satisfactory than amputation of the affected toe at the metatarso-phalangeal joint, as after this the adjacent toes tend to fall together and favour hallux valgus. If amputation is performed, a pad of cotton wool or rubber prop should be worn to fill up the vacant s.p.a.ce.

The term _Gampsodactyly_ has been applied to a deformity in which all the toes a.s.sume the position of hammer-toe, usually from a spastic condition of the muscles controlling the toes.

#Hypertrophy of the Toes.#--One or more of the toes may be the seat of hypertrophy or local giantism. This is usually present at birth or appears in early childhood, and may form part of an overgrowth involving the entire lower extremity (Fig. 162). The overgrowth may involve all the tissues equally, or the subcutaneous fat may be specially affected. The medial toes are those most commonly hypertrophied. In addition to being enlarged, the toe may be displaced from its normal axis. The hypertrophy may affect two or more toes which are fused together or webbed (Fig. 162). The treatment consists in amputating as much of the toe as will allow of an ordinary boot being worn.

[Ill.u.s.tration: FIG. 162.--Congenital Hypertrophy of Left Lower Extremity in a boy aet. 5. The second and third toes are fused.]

#Supernumerary Toes# (_Polydactylism_).--These vary from mere appendages of skin to fully developed toes (Fig. 163); if they interfere with the wearing of boots they should be removed.

#Webbing of the Toes# (_Syndactylism_).--This may affect two or more toes, which may be united merely by a web of skin, or so completely fused that the individual digits are only indicated by the nails; the degree of fusion is shown by means of skiagrams. Unless a.s.sociated with congenital hypertrophy, no treatment is called for.

[Ill.u.s.tration: FIG. 163.--Supernumerary Great Toe.

(Photograph lent by Sir George T. Beatson.)]

THE UPPER EXTREMITY

#Congenital Absence of the Clavicle.#--Both clavicles may be absent, and it is possible for the patient voluntarily to bring his shoulders into contact with one another in front of the chest; there is little or no impairment of function.

#Displacements of the Scapula.#--_Congenital Elevation of the Scapula_ (Sprengel's shoulder, 1891).--This abnormality is rare, and is not usually recognised till several years after birth. In one variety there is a bridge of bone or fibrous tissue connecting the superior angle of the scapula with the spinous process of one of the cervical vertebrae, and there may be a false joint at one end of the bridge permitting a certain amount of movement of the scapula. a.s.sociated abnormalities in the vertebrae and in the ribs are shown in skiagrams.