posterior ligaments of the ankle, the plantar fascia, the
calcaneo-navicular ligaments, and the tibialis posterior tendon. The
varus deformity may then be corrected by laying the foot on its
lateral side on a padded triangular wooden block, and pressing
forcibly on the anterior and posterior ends of the foot so as to undo
the curve on its medial side and allow of abduction of the foot; this
is usually attended with cracking as the shortened ligaments give way.
The equinus element is next dealt with by forcibly dorsiflexing the
foot until the deformity is over-corrected. If it is preferred to
correct the deformity in stages instead of at one sitting, the equinus
element is left to the last. In older children, the strength of the
hands is usually insufficient to stretch the tissues, and mechanical
wrenches may be employed, such as those devised by Thomas, Bradford,
or Lorenz.
_Resection of a wedge from the tarsus_ (Davies Colley, 1876) is
reserved for the most severe cases in which the shape and rigidity of
the bones prevent correction of the deformity by any other means. The
base of the wedge is on the lateral aspect, and the bone removed
includes parts of the calcaneus, cuboid, talus, and navicular.
_Removal of the talus_ is an alternative operation to resection of the
tarsus, and may yield equally good results.
In children, before the tarsal bones have become completely ossified,
Ogston's method yields good results; instead of removing a wedge from
the tarsus, the osseous nucleus of each bone is gouged out, leaving
the cartilaginous shell. In this way the intertarsal joints are not
interfered with, and the cartilaginous tarsus can be moulded so that
when ossification is completed the bones differ but little from the
normal.
After any of these operative procedures, manipulations, massage,
exercises, electrical stimulation of the muscles, and the wearing of
some apparatus must be persevered with for at least twelve months.
Failures are due to not sufficiently over-correcting the deformity in
the first instance, and to neglect of after-treatment; in hospital
practice it is difficult to ensure continuous supervision over long
periods.
Finally, _amputation_ may be called for when other methods have
failed, and the patient is unable to put the foot to the ground
because of suppurating bursae and ulceration of the skin.
#Acquired Talipes Equino-varus.#--In the great majority of cases this
condition results from anterior poliomyelitis. It especially affects
the peronei and the extensors of the toes, and is unilateral. The
patient is unable to dorsiflex and abduct the foot, which hangs with
the toes pointed and the sole turned medially.
At first the joints are flaccid, and the attitude can easily be
corrected by manipulation. In course of time, however, the opposing
muscles--those inserted into the tendo Achillis, the tibialis
posterior, and the long flexors of the toes--become shortened, and
there is secondary contraction of the plantar fascia and of the
ligaments on the medial side of the foot, and the deformity is thus
rendered permanent. The bones also are altered in their shape and
mutual relations, the talus being rotated forwards so that a large
portion of its trochlear surface protrudes from the tibio-fibular
socket. The skin is cold and livid, and readily suffers from pressure
sores. The whole limb is ill-developed, and may be shorter than its
fellow, and the paralysed muscles are wasted and exhibit for a time
the reaction of degeneration.
A similar deformity may result from section of the peroneal (external
popliteal) nerve, from the peroneal form of progressive muscular
atrophy, and from peripheral neuritis.
The _treatment_ of paralytic equino-varus, short of operation, has
been referred to under anterior poliomyelitis (p. 242). If tendon
transplantation is indicated, the tendon of the tibialis anterior is
attached to the cuboid, and a strip of the tendo Achillis to the
dorsal aspect of the tarsus. Jones displaces the tibialis anterior
into the base of the fifth metatarsal.
If the paralysis is widely distributed, and the joints are flail-like,
it is better to ankylose the ankle and mid-tarsal joints. It may be
necessary to divide in several places the plantar fascia and other
structures that have undergone secondary shortening.
As using the limb hastens the restoration of function, the child
should be got on to his feet as soon as possible.
The spastic form of talipes equino-varus is comparatively rare. The
plantar flexors and invertors distort the foot into the equino-varus
attitude. 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 associated 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 balls 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 attitude of
plantar-flexion. In a limited number of cases the equinus attitude is
assumed to compensate for shortening of the limb.
[Illustration: 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."
[Illustration: 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 balls 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).
[Illustration: 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 balls 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 balls 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 stitched 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.
[Illustration: FIG. 148.--Pes Calcaneo-valgus with excessive arching
of foot.]
[Illustration: 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
balls 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 massage 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 PLANUS 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 pronated and abducted. The term
_pes planus_ is applicable when there is merely loss of the arch; _pes
valgus_ when the foot is pronated 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, gonorrhoeal, and tabetic.
[Illustration: FIG. 150.--Pes Cavus in association with Pes Equinus,
the result of Poliomyelitis.]
[Illustration: 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.
[Illustration: 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 attitude 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
attitude of rest," consists in standing with the limbs apart, the
knees slightly flexed, the legs slightly rotated laterally at the
knee, and the feet pronated, 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.
[Illustration: 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 attitude 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 passing 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 pronounced, 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 associated 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 balls 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 balls 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
potassium, 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.
[Illustration: 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 balls 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 balls of the toes; a second, in which
the normal attitude 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 massaged 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 balls
of the toes. He should neither stand nor walk long enough to cause
fatigue, and in standing he should alter the attitude of the feet from
time to time, and occasionally rise on the balls of the toes. The
following exercises, devised by Ellis of Gloucester, should be
practised: (1) Rising on the balls of the toes, the toes being
directed straight forwards; (2) rising on the balls 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 attitude, after rising on to the balls
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, circumduction 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 attitude 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.
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 constitute 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.
[Illustration: 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
attitude. 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 pronated, 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 association 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 gonorrhoea,
arthritis deformans, tuberculosis, and Charcot's disease; the
gonorrhoeal 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 attitude of the foetus
_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-planus.#--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 associated 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 associated 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 balls 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 balls of the toes. The affection is of
insidious development, and is usually ascribed to sinking of the
transverse arch of the foot--pes transverso-planus--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.
[Illustration: 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, massage, 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
adventitious bursa is formed, which, when thickened by chronic
inflammation, constitutes 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 associated with flat-foot.
[Illustration: 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 pronounced 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
pronounced cases, the pain and tenderness must first be got rid of by
rest and soothing applications. At night, the attitude 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 balls 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.
[Illustration: 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.
[Illustration: 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 associated with flat-foot, and is then usually bilateral. The
patient's gait, in addition to having the characteristic features
associated with flat-foot, is peculiarly wooden and inelastic, as
instead of rising on the balls 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 puberty, and is then, as a rule,
bilateral, and often associated with flat-foot.
The first phalanx is dorsiflexed, and the second is plantar-flexed,
while the third varies in its attitude, 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.
[Illustration: 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.
[Illustration: 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 passing 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 space.
The term _Gampsodactyly_ has been applied to a deformity in which all
the toes assume 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.
[Illustration: 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 associated
with congenital hypertrophy, no treatment is called for.
[Illustration: 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. Associated
abnormalities in the vertebrae and in the ribs are shown in skiagrams.
In the more common type, the scapula seems to be held in its elevated
position by shortening of the muscles attached to its body, and it is
often rotated so that its lower angle is close to the spine and its
axillary border nearly horizontal, or the axillary border may lie in
close to the ribs, and the vertebral border project from the chest
wall. The shoulder is generally higher and farther forward on the
affected side, and there is a moderate degree of scoliosis. There is a
want of purchase in the movements of the shoulder and upper arm.
[Illustration: FIG. 164.--Congenital elevation of Left Scapula in a
girl: also shows hairy mole over Sacrum.
(Mr. D. M. Greig's case.)]
When the deformity is bilateral, which is rare, the neck is short and
thick, the chin lies close to the sternum, and the arms can scarcely
be raised to the horizontal.
Gymnastic exercises and the wearing of a brace to hold the shoulders
back and down may be followed by some improvement, but, as a rule, it
is necessary to mobilise the scapula by operation. An X-ray photograph
should first be taken, because, when the scapula is connected with the
spine by a bridge of bone, this must be resected. The muscles attached
to the vertebral border and spine of the scapula are divided, the
bone is drawn down to its proper position, and the parts are fixed by
plaster bandages.
_Winged Scapula._--This condition consists in a marked displacement
backwards of the lower angle and vertebral border of the scapula, when
the patient attempts to raise the arm from the side (Fig. 165). Under
normal conditions, in making this movement the serratus and rhomboid
muscles pull forward the vertebral border and inferior angle of the
scapula, and so fix the bone firmly against the chest wall. When these
muscles are paralysed, as a result of anterior poliomyelitis,
neuritis, or injury of the long thoracic nerve of Bell, or of the
fifth and sixth cervical nerve-roots through which they receive their
supply, the patient is unable to abduct the arm, and the deltoid
having lost its _point d'appui_, its contraction merely results in
tilting the angle of the scapula backward (Fig. 165).
[Illustration: FIG. 165.--Winged Scapula; the patient is holding the
arms out in front.]
_Treatment._--In the majority of recent cases the condition yields to
the administration of strychnin and other muscle and nerve tonics, and
the use of massage and the faradic current. The application of a
carefully adjusted padded belt is sometimes useful. The method of
treatment by stitching the latissimus dorsi over the lower angle of
the scapula is based on the erroneous assumption that the displacement
is due to the slipping of that muscle off the bone; at the same time,
it must be admitted that the operation sometimes diminishes the
deformity and adds to the patient's comfort.
A more efficient method consists in detaching the clavicular portion
of the pectoralis major from its insertion, and stitching it to the
serratus anterior so as to make it take on the function of this
muscle, or stitching it to the axillary border of the scapula. Success
has also followed suture of the vertebral border of the scapula to the
subjacent ribs (Eiselsberg).
_Displacement of the scapula upwards and laterally_ has been observed
as a result of partial paralysis of the trapezius when the nerves
supplying it have been divided in removing tuberculous glands from the
neck. In these acquired displacements, treatment is directed towards
the nerve lesion and towards the improvement of the muscles by
electricity, massage, and exercises; when the paralysis of the
trapezius is permanent, the disability is gradually overcome by the
compensatory hypertrophy of the levator muscle.
#Congenital Dislocation of the Shoulder.#--This rare condition is
usually bilateral, and is associated with other congenital defects.
The glenoid cavity is deformed or absent, and the dislocation may be
sub-coracoid, sub-acromial, or sub-spinous. The movements of the arm
are restricted, and the development of the extremity as a whole is
imperfect. It is sometimes possible to reduce the dislocation by
manipulation, or, if this fails, by operation. Unilateral dislocation
is sometimes mistaken for dislocation that has occurred during
delivery and _vice versa_.
#Habitual Dislocation# is described on p. 65.
#Paralytic Deformities--Paralytic Dislocation of the Shoulder.#--The
muscles in the region of the shoulder may have their innervation
interfered with as a result of various conditions, of which
poliomyelitis and injuries of the brachial plexus at birth are the
most important. The capsular ligament of the shoulder-joint, being no
longer kept tense by the scapular muscles--especially the deltoid and
lateral rotators--becomes relaxed, and is gradually stretched by the
weight of the arm. The appearances are characteristic; the muscles of
the shoulder are wasted, the acromion is prominent, and between it and
the upper end of the humerus there is a marked hollow into which one
or more fingers may be inserted. The arm hangs flaccid by the side,
rotated medially and pronated, and moves in a flail-like fashion in
all directions, the patient having little control over it. The best
results are obtained by the transplantation of muscles, the trapezius
being detached from the clavicle and stitched to the surface of the
deltoid, and the upper arm fixed in the position of horizontal
abduction with the arm rotated laterally and supinated. Bradford
inserts a portion of the trapezius into the humeral insertion of the
deltoid. When these methods are impracticable, the upper arm may be
fixed to the trunk by some form of apparatus, or arthrodesis is
performed so that the movements of the scapula are communicated to the
upper arm; the best attitude for ankylosis is one of abduction with
medial rotation, so that the hand can be brought to the mouth.
In cases of poliomyelitis, when all the muscles governing the elbow
are paralysed while the muscles of the hand have escaped, it may be of
great service to fix this joint permanently at rather less than a
right angle. This may be effected by arthrodesis, or by removing an
extensive diamond-shaped portion of skin from the flexor aspect of the
joint and bringing the raw surfaces together, commencing the stitching
at the lateral apices of the gap.
[Illustration: FIG. 166.--Arrested Growth and Wasting of Tissues of
Right Upper Extremity, the result of Anterior Poliomyelitis in
childhood.]
#Congenital Dislocations at the Elbow.#--_The head of the radius_ may
be dislocated forwards, backwards, or laterally--usually in
association with imperfect development of the radius and of the
lateral condyle of the humerus. When the displaced head of the bone
interferes with supination, or with extension, it should be removed.
Congenital dislocation of both bones of the forearm is extremely rare.
#Cubitus Valgus# and #Cubitus Varus#.--When the normal arm hangs by
the side with the palm of the hand directed forward, the forearm and
upper arm form an angle which is open outwards--known as the "carrying
angle"; it is usually more marked in women in association with the
greater breadth of the pelvis and the relative narrowness of the
shoulders. When this angle is increased, the attitude is described as
one of _cubitus valgus_. This deformity may be acquired as a result of
rickets, but more commonly it is due to fracture of the lateral
condyle of the humerus, in which the separated fragment has been
displaced upwards.
_Cubitus varus_ is the reverse of cubitus valgus. It is more common,
is always pathological, and is nearly always a result of fracture of
the lower end of the humerus or separation of the lower humeral
epiphysis and subsequent interference with growth. These deformities
may be corrected by supra-condylar osteotomy of the humerus.
[Illustration: FIG. 167.--Lower end of Humerus from case of Cubitus
Varus.]
#Synostosis of the superior radio-ulnar joint# is a rare congenital
condition, in which the hinge movements at the elbow are free, but
supination is impossible; an attempt may be made by operation to form
a new joint.
#Volkmann's ischaemic contracture# of the muscles of the forearm,
resulting in the production of claw-hand, is described in Volume I.,
p. 415.
#Deformities of the Forearm and Hand.#--The _radius_ may be absent
completely or in part, frequently in combination with other
malformations. The most evident result is a deviation of the hand to
the radial side--one variety of _club-hand_. The forearm is
shortened, the ulna thickened and often bent, and the thumb and its
metacarpal bone are often absent, so that the usefulness of the hand
and arm is greatly impaired (Fig. 171). For this condition Bardenheuer
devised an operation which consists in splitting the lower end of the
ulna longitudinally and inserting the proximal bones of the carpus
into the cleft.
Congenital deficiency of the _ulna_ is extremely rare.
#Intra-uterine amputation# by constriction of amniotic bands sometimes
occurs (Figs. 168, 169).
[Illustration: FIG. 168.--Intra-uterine Amputation of Forearm.]
[Illustration: FIG. 169.--Radiogram of Arm of patient shown in Fig.
168.]
#Drop Wrist from Anterior Poliomyelitis.#--In this condition the
capacity of extending the fingers is deficient or absent. Recovery can
be confidently predicted if, on still further flexing the fingers,
they can be voluntarily extended towards the point from which they are
flexed (Tubby and Jones). Considerable improvement may result from
fixing the hand by means of a splint in the attitude of dorsal
flexion. The splint is removed at frequent intervals to allow of
massage and other treatment being carried out, and it has usually to
be worn for a period of one to two years. In some cases recourse
should be had to arthrodesis.
[Illustration: FIG. 170.--Congenital absence of Left Radius and Tibia
in a child aet. 8.
(Mr. D. M. Greig's case.)]
In _spastic paralysis_ the most pronounced deformity is flexion of the
forearm and pronation and flexion of the hand (Fig. 166). Gradual
extension at the wrist may be brought about by the use of a malleable
splint, in which the angle is gradually increased, over a period of at
least twelve months. Failing success by this method, operation may be
had recourse to, and this consists in lengthening of tendons, and
tendon transplantation. Tubby has devised an operation for converting
the pronator radii teres into a supinator, and Robert Jones another in
which the flexors of the carpus are made to take the place of the
extensors. "These operations, combined if necessary with elongation of
the flexors of the fingers, pave the way for diminution of the angle
of flexion at the elbow, lessening of the pronator spasm, increase of
the supinating power, reduction of the carpal flexion, and addition to
the extensor power at the wrist" (Tubby and Jones).
#Congenital Club-hand.#--This rare deformity corresponds to congenital
club-foot, and probably arises in the same way. The hand and fingers
are rigidly flexed to the ulnar or radial side, so that the patient is
incapable of moving them. Treatment is carried out on the same lines
as for club-foot.
A deformity resembling this, _acquired club-hand_, is brought about
when the growth of either of the bones of the forearm has been
arrested as a result of disease or of traumatic separation of its
lower epiphysis. The hand deviates to the side on which the growth has
been arrested--_manus valga_ or _vara_. The treatment consists in
resecting a portion of the longer bone.
[Illustration: FIG. 171.--Club-hand, the result of imperfect
development of radius. The thumb is absent.
(Photograph lent by Sir George T. Beatson.)]
#Madelung's Deformity of the Wrist.#--In 1878, Madelung called
attention to a deformity also called sub-luxation of the hand, in
which the lower articular surface of the radius is rotated so that it
looks towards the palm; there is palmar displacement of the carpus,
and the lower end of the ulna projects on the dorsum. The cause of the
condition is obscure, but it is met with chiefly in young women with
slack ligaments, whose laborious occupation or athletic pursuits
subject the hand and wrist to long-continued or repeated strain. It is
as frequently unilateral as bilateral and may recur in successive
generations. There is a good deal of pain, the grasping power of the
hand is impaired, and dorsiflexion is considerably restricted. The
deformity disappears on forcible traction, but at once reappears when
the traction is removed. A wristlet of poroplastic or leather
extending from the mid-forearm to the knuckles is moulded to the limb
in the corrected position, and is taken off at intervals for massage
and exercises.
When _operative treatment_ is called for, it takes the form of
osteotomy of the radius and ulna about an inch or more above their
articular surfaces.
#Congenital dislocation of the wrist# is rare.
#Deformities of the Fingers.#--Various forms of _congenital
dislocation_ of the fingers are met with, but they are of little
clinical importance, as they interfere but slightly with the
usefulness of the digit affected.
_Congenital lateral deviation of the phalanges_ is more unsightly than
disabling; it is met with chiefly in the thumb, in which the terminal
phalanx deviates to the radial or to the ulnar side in extension; the
deviation disappears on flexion.
_Congenital contraction of the fingers_ is comparatively common. It is
an inherited deformity, and is often met with in several members of
the same family. It most frequently affects the little or the ring and
little fingers (Fig. 172), and is usually bilateral. The second and
third phalanges are flexed towards the palm; the first phalanx is
dorsiflexed, this being the reverse of what is observed in Dupuytren's
contraction. Duncan Fitzwilliams suggests that it should be called
"hook-finger," and that it is probably due to imperfect development of
the anterior ligament of the first inter-phalangeal joint. He has
observed it in association with laxity of the ligaments of the other
joints of the body.
[Illustration: FIG. 172.--Congenital Contraction of Ring and Little
Fingers.]
The affection is usually disregarded in infancy and childhood as being
of no importance. In young children, the deformity is corrected by
wearing a light splint fixed with strips of plaster, or a piece of
whalebone or steel inside the finger of a glove. In older children,
the finger may be straightened by subcutaneous division of the
ligament over the palmar aspect of the base of the middle phalanx, or
failing this by lengthening the flexor tendons and resecting a wedge
from the dorsal aspect of the first phalanx close to the
inter-phalangeal joint.
#Dupuytren's Contraction.#--This is an acquired deformity resulting
from contraction of the palmar fascia and its digital prolongations
(Fig. 173). It is rare in childhood and youth, but is common after
middle life, especially in men. It is often hereditary, and is said to
occur in those who are liable to gout and to arthritis deformans.
While it is met with in the working-classes and attributed to the
pressure of some hard object on the palm of the hand--such as a hammer
or shovel or whip--its greater frequency in those who do no manual
work, and the fact that it is very often bilateral, indicate that the
constitutional factor is the more important in its causation.
[Illustration: FIG. 173.--Dupuytren's Contraction.]
In the initial stage there is a localised induration in the palm
opposite the metacarpo-phalangeal joint, and the skin over it is
puckered and closely adherent to the underlying fascia. After a
variable interval, the finger is gradually and progressively flexed at
the metacarpo-phalangeal joint. The ring finger is usually the first
to be affected, less often the fifth, although both are commonly
involved. It is rarest of all in the index. The flexion may be
confined to the metacarpo-phalangeal joint, or the middle and distal
phalanges may also be flexed; and as the deformity becomes more
pronounced, the nail of the affected finger may come into contact with
the skin of the palm. Dissections show that the flexion of the finger
is the result of a chronic interstitial overgrowth or fibrositis and
subsequent contraction of the palmar fascia and of its prolongations
on to the sides of the fingers. The digital processes of the fascia
are thickened and shortened, and come to stand out like the string of
a bow. The adipose tissue in the skin of the palm disappears, and the
skin and fascia thus brought into contact become fused. The tendons
and their sheaths are not implicated; they are found lying deeply in
the concavity of the curve of the flexed digit. There is no pain, but
the grasp of the hand is interfered with, the patient is unable to
wear an ordinary glove, and he may be incapacitated from following his
occupation.
The condition is easily diagnosed from congenital contraction by the
fact that in the latter the proximal phalanx is dorsiflexed.
_Treatment._--When seen in the initial stage, contraction may be
prevented by passive movements of the finger and by massage of the
indurated fascia; we have observed cases in which these measures have
held the malady in check for many years, but when flexion has already
occurred, they are useless, and according to the social position,
habits, or occupation of the patient, the condition is left alone or
the deformity is corrected by operation.
Adam's operation consists in multiple subcutaneous division of the
contracted fascia in the palm and of its prolongations on to the
finger; in addition to dividing the fascia, the tenotomy knife should
be used also to separate the skin from the fascia. The finger is then
forcibly extended, and a well-padded splint secured to the hand and
forearm. The skin on the palmar aspect opposite the first
inter-phalangeal joint may give way when the finger is extended;
should this occur, the resulting gap may be covered by a skin graft.
After healing has occurred, massage and movements must be persevered
with, and a splint (Fig. 174) worn at night, as there is an inveterate
tendency to recurrence of the contraction. In view of this tendency
there is much to be said in favour of the radical operation which
consists in removal of the fascia by open dissection. Owing to the
long time required for healing and the sensitiveness of the scar, the
results of excision of the fascia are sometimes disappointing. Greig
has obtained good results by resecting the head of the metacarpal
bone. When the little finger is completely flexed towards the palm it
may be amputated, as it is always in the way.
[Illustration: FIG. 174.--Splint used after Operation for Dupuytren's
Contraction.]
#Supernumerary Fingers (Polydactylism).#--These may coexist with
supernumerary toes, and the condition is often met with in several
members of the same family. Sometimes the extra finger is represented
by a mere skin appendage, the nature of which may only be indicated by
the presence of a rudimentary nail; sometimes it contains bone
representing one or more phalanges, or it may be fully formed (Fig.
175). In the majority of cases the superfluous finger should be
removed.
[Illustration: FIG. 175.--Supernumerary Thumb.
(Photograph lent by Sir George T. Beatson.)]
#Congenital Deficiencies in the Number of Fingers.#--One or more
fingers may be absent, such deficiency being often associated with
imperfect development of the radius or ulna; or they may be
represented by short rounded stumps, which are ascribed to the
strangulation of the digits by amniotic bands _in utero_--the
so-called intra-uterine amputation.
#Webbing of Fingers (Syndactylism).#--Congenital webbing or fusion of
the fingers may be associated with polydactylism or with congenital
hypertrophy, and, like other digital deformities, may affect several
members of the same family. The degree of fusion ranges from a web of
skin joining the fingers to a fusion of the bones, the latter being
well seen in skiagrams. If an operation is decided upon, it should not
be performed until the age of five or six years. In the simplest cases
it is only necessary to divide the web and to unite the cut edges of
skin along each finger by sutures, a skin graft being inserted into
the angle between the fingers. An operation in which the skin is
dissected up in the form of flaps may be required, but it should not
be lightly entered upon, as in young children it has been known to be
followed by gangrene of one or more of the digits.
#Congenital Hypertrophy of the Fingers.#--This is a form of local
giantism affecting one or more digits, and involving all the tissues.
The finger is usually of abnormal size at birth, and continues to
grow more rapidly than the others, and it may also come to deviate
from its normal axis. Such a finger should be trimmed down or removed,
to permit of the use of the other digits.
#Trigger Finger# (Fig. 176).--This is an acquired condition in which
movement of a finger or thumb, either in flexion or extension, is
arrested, and is only completed with the assistance of the other hand.
The obstacle to movement is usually overcome with a jerk or snap
suggesting a resemblance to the trigger of a gun or the blade of a
clasp-knife. The commonest cause is a disproportion between the size
of the tendon and its sheath, such as may result from a localised
thickening of the tendon. Recovery usually takes place under massage
and passive movements. Failing this, the thickened portion of the
tendon is pared down to its normal size; if it is the sheath of the
tendon that is narrow, it is laid freely open.
[Illustration: FIG. 176.--Trigger Finger.
(Photograph lent by Sir George T. Beatson.)]
#Drop# or #mallet finger# is described on p. 121.