Club-Foot

Club-Foot (talipes), the name given to deformities of the foot, some of which are congenital, others acquired—the latter being chiefly due to infantile paralysis. Talipes equinus is that form in which the heel does not touch the ground, the child resting on the toes. In talipes varus the foot is turned inwards and shortened, the inner edge of the foot is raised, and the child walks on the outer edge. These two conditions are often combined, the heel being drawn up and the foot twisted inward; the name given to the twofold deformity is talipes equino-varus. It is the most usual congenital form. In talipes calcaneus the toes are pointed upwards and the foot rests on the heel. This is always an acquired (paralytic) deformity.

The treatment of congenital club-foot, which is almost invariably varus or equino-varus, should be begun as soon as ever the abnormal condition of the foot is recognized. The nurse should be shown how to twist and coax the foot into the improved position, and should so hold it in her hand many times a day. And thus by daily, or, one might almost say, hourly manipulations, much good may be accomplished without distress to the infant. If after weeks or months of these measures insufficient progress has been made, the subcutaneous division of a tendon or two, or of some tendons and ligaments may be necessary, the foot being subsequently fixed up in the improved position in plaster of Paris. If these subcutaneous operations also prove disappointing, or if after their apparently successful employment the foot constantly relapses into the old position, a more radical procedure will be required. Of the many procedures which have been adopted there is, probably, none equal to that of free transverse incision introduced by the late Dr A. M. Phelps of New York. By this “open method” the surgeon sees exactly what structures are at fault and in need of division—skin, fasciae tendons, ligaments; everything, in short, which prevented the easy rectification of the deformity. After the operation, the foot is fixed, without any strain, in an over-corrected position, between plaster of Paris splints. By the adoption of this method the old instrument of torture known as “Scarpa’s shoe” has become obsolete, as have also some of those operations which effected improvement of the foot by the removal of portions of the bony arch. Phelps’s operation removes the deformity by increasing the length of the concave border of the foot rather than by shortening the convex borders as in cuneiform osteotomy; it is a levelling up, not a levelling down.

Talipes valgus is very rare as a congenital defect, but is common enough as a result of infantile paralysis and as such is apt to be combined with the calcanean variety. “Flat-foot” is sometimes spoken of as spurious talipes valgus; it is due to the bony arches of the foot being called upon to support a weight beyond their power. The giving way of the arches may be due to weakness of the muscles, tendons or ligaments—probably of all three. It is often met with in feeble and flabby children, and in nurses, waiters, policemen and others whose feet grow tired from much standing. Exercises on tip-toe, especially with a skipping rope, massage, rest and tonic treatment will give relief, and shoes or boots may be supplied with the heel and sole thickened along the inner borders so that the weight may be received along the strong outer border of the foot. When the flat-footed individual stands it should be upon the outer borders of his feet, or better still, when convenient, on tip-toe, as this posture strengthens those muscles of the leg which run into the sole of the foot and hold up the bony arches. In certain extreme cases the surgeon wrenches the splay feet into an inverted position and fixes them in plaster of Paris, taking off the casing every day for the purpose of massage and exercises.

Flat-foot is often associated with knock-knee in children and young adults who are the subject of rickets.

Morton’s Disease.—In some cases of flat-foot the life of the individual is made miserable by neuralgia at the root of the toes, which comes on after much standing or walking, the distress being so great that, almost regardless of propriety, he is compelled to take off his boot. The condition is known as Morton’s disease or metatarsalgia. The pain is due to the nerves of the toes (which come from the sole of the foot) being pressed upon by the rounded ends of the long bones of the foot near the web of the toes. It does not generally yield to palliative measures (though rest of the foot and a change to broad-toed, easy boots may be helpful), and the only effectual remedy is resection of the head of one of the metatarsal bones, after which relief is complete and permanent.

For paralytic club-foot, in which distressing corns have been developed over the unnatural prominences upon which the sufferer has been accustomed to walk, the adoption of the most promising conservative measures are usually disappointing, and relief and happiness may be obtainable only after the performance of Syme’s amputation through the ankle-joint.

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