Bow-legs.
In bow-legs the concavity of the curve is on the inside instead of the outside of the limbs. Thus, the knees are unduly separated, instead of the feet. The bending, also, is commonly more grad ual instead of angular as in knock-knees.
The causes are much the same, but the affection usually occurs between the ages of one and six years and less fre quently in older subjects. It is more commonly, also, of a distinct rachitic origin. The appearance of the limbs of the patient is so marked that it is less apt to be overlooked than is the case with knock-knees. In the latter affection, as has been said, a position of valgus is often assumed by the foot. This is turned so as to enable the sole to be placed flat on the ground. In bow-legs the sole has a tendency to incline in ward; so that in order to bring the sole flat on the ground the feet are widely separated; therefore the feet are very far apart as well as the knees, and this gives a peculiar appearance to the pa tient, which is at once remarked by the parents.
The bowing may involve the tibia and fibula alone or the femur in addition. The knee-joint itself is not often affected. The curve is not always a lateral one, but may be in an antero-posterior direc tion, often combined with lateral bend ing.
Treatment.—The line of treatment to be pursued depends on the age of the child and extent and character of the deformity. As the nutrition of the pa tient is almost always at fault, particular attention should be paid to it. As it is evident that the child has not grown satisfactorily on its previous feeding and mode of life, the usual diet should be changed and the child be gotten out in the open air as much as possible and codliver-oil and hypophosphites given internally or the former rubbed thor oughly in the skin daily.
In endeavoring to straighten the limbs by non-operative mechanical means the child may either be kept abed or allowed to walk around. If it is desired to ob tain the greatest possible correction in a short time the child is to be kept in bed and the limbs bandaged to each side of a splint placed between them. When
the curvature is confined to the bones of the leg a very efficacious method is the following, which I devised some years ago: A pad is placed between the ankles, and these are then firmly fastened to gether with a bandage; another pad is placed between the knees, and they like wise are bound firmly together. The legs are then covered with a plain mus lin bandage and directly across from one leg to the other at the point of greatest curvature is placed a rubber bandage. This by its continuous pressure tends to obliterate the curve. Care should be taken not to apply the rubber bandage too tightly.
If the child is to be allowed to walk around freely braces must be employed. These are often made of a single inside bar. This form, however. is not so firm, nor does it make so efficacious pressure as does a double brace. It is best to have a brace made with two side-irons jointed at the ankle and knee. A pad is placed over the inside of the ankle, another at the knee, and a third on the opposite side of the leg. By bending the apparatus every few weeks any desired degree of pressure can be obtained. It is highly desirable to carry the apparatus above the knee so that rotation be prevented. A fairly efficient apparatus can be made for very young children without any ankle-joint, as it is hardly so essential in them as in adults.
In cases of antero-posterior curvature an apparatus with two side-irons and a pad strapped over the projecting bone and fastened to the side-irons is of serv ice, but the results are not so good as in lateral curves. In young children with soft bones correction can be effected by manual force and the limb placed in a plaster-of-Paris dressing.
In more stubborn cases osteotomy or osteoclasis may be utilized. Personally I do not like osteoclasis, and prefer an osteotomy. This can be done through an opening sufficient only to admit the chisel. To break the bone I prefer an osteoclast to manual force, as it necessi tates less division of bone. The bone is thus accurately broken at the desired spot without undue violence.