Talipes Equinus.—In talipes equinus the heel is elevated and the patient walks on his toes after the manner of a horse; hence the name. It is usually an acquired affection. In infantile pa ralysis the loss of power in the anterior muscles of the leg allows the unopposed muscles of the calf to draw the heel ward. For a certain length of time after paralysis has occurred the foot can be brought to its normal position, but, if no means are taken toward guarding against drawing up of the heel, the healthy muscles and tendo Achillis will permanently shorten and thus the de formity will be produced. It is a con dition which commonly occurs as a sequence of injuries of the leg. In fractures, particularly if much violence has been clone in the neighborhood of the ankle, and attention is not paid to the position of the foot, when the time comes for the patient to walk the foot will be found to be more or less firmly fixed in the position of equinus. Again, after injuries of the deep structures of the back of the leg the same condition is produced. Cicatrices will not infre quently draw the heel up.
Treatment.—The treatment in cases in which this deformity is liable to occur should be directed to preventing it. In cases of infantile paralysis patients with toe-drop are liable to suffer from con traction. In order to avoid this an effi cient brace can be worn consisting of a sole-plate and two side-irons (or even one) with a joint at the ankle which pre vents the foot being extended to more than a right angle. It may be made to be worn inside the shoe or outside and fastened to the sole. In cases of injuries and fractures some splint or appliance should be used which prevents the heel from being drawn up. If the condition is already present when the patient is seen, if it is not too resistant, massage and manual stretching followed by the application of a right-angled splint will suffice to bring the foot to a normal posi tion. This once accomplished, a ing-brace should be prescribed or a light firm splint—such as can be made of leather or silicate of soda—may be used to hold the foot at right angle. When the affection is of longer duration the tendo Achillis should be divided and the case treated as already detailed.
In old cases the plantar fascia will be found contracted as well, oftentimes, as the tendons of the toes. These should all be divided, the toes flattened out, the foot unfolded, and the heel brought down. In cases which have resulted from paralysis of the leg-muscles ticular care should be taken not to un duly lengthen the tendo Achillis, or else control of the foot will be much lessened and walking will be made worse.
In proper cases the removal of a wedge of bone from the tibia and fibula im mediately above the ankle-joint advo cated, in preference to tarsectomy, for the purpose of removing equinus, which will not yield to milder measures. Regi
nald H. Sayre (Amer. Medico-Surg. Bull., Dee. 15, '95).
Talipes Calcaneus.
Diagnosis.—This may be either con genital or acquired. The foot is drawn up toward the leg and the heel is down. Division of tendons in these cases is not often required; all that is necessary is to apply some sort of splint or brace that will maintain the foot at a right angle. If the case is a walking one an apparatus with an ankle stop-joint that allows ex tension, but not flexion, will be required.
Shortening of the tendo Achillis may be performed in these cases. The tendon should be divided obliquely and the ends overlapped and fastened with a couple of fine silk sutures—introduced back and forth, as in a mattress-suture. The wound should be closed without drainage and the foot placed in a splint.
Pes Cavus.
Diagnosis and Treatment.—In certain cases of paralysis the heel assumes the position of calcaneus, as above described, while in addition the anterior leg-mus cles are paralyzed, thus allowing the toes to drop. This condition allows the heels and toes to come closer together and consequently relaxes the normal tension on the plantar ligaments. This tendency is aggravated by the action of the an terior and posterior tibials, which, if healthy, will draw the arch of the foot up. Thus is brought about a hollowing of the sole of the foot, which is called pes caves. The arch is raised, while the toes and heel are depressed. In treating it several indications are to be met: To aid in straightening out the contracted arch the plantar fascia should be di vided. The anterior and posterior tibial muscles should not be divided, because in these feet there are already too many disabled muscles. An attempt may be made to shorten the tendo Achillis as de tailed under the head of talipes cal caneus. To keep the toes from dropping a steel sole-plate and side-iron brace should be used with a stop ankle-joint allowing flexion,- but not extension be yond a right angle. To keep the foot flat on the sole-piece a strap should pass from side to side over the instep, or else particular pains should be taken to lace the foot firmly down in the apparatus. I have also used in these cases an apparatus with a vertical steel spring, which allowed certain amount of both extension and flexion and then brought the foot to a right angle. A. M. Phelps has improved this appliance by adding a stop-joint that prevents sud den excessive movements from breaking the spring.