GENU VALGUM (Knock-Knee).
lloth this condition and the opposite one of Genu or bow-knee, are nearly always the result of rickets; occasionally they may result in weak, underfed boys by prolonged standing or the carrying of heavy weights which cause the ligaments of the knee-joint to stretch.
The treatment of both affections in the early stages will consist of rest in bed in order to take the weight of the body from off the yielding bones or ligaments. The internal remedies—Cod-Liver Oil, &c.—well regulated dietary, suitable to the rickety condition, are to be persevered with, whilst massage and forcible though painless manipulation of the bones are to be daily practised.
As open-air life is to be maintained as completely as possible a splint may be applied along the limb, reaching from the pelvis to well below the foot, so as to prevent the child from standing. By careful padding of the splint and by the judicious use of an elastic bandage a mild degree of pressure may he continuously kept up in order to straighten the bent bones, and the child can he carried out into the open air. A double Thomas's hip splint with knee-bars and head-piece is usually very suit able. In poor children where the adjustment of splints becomes an impracticable procedure the leg may be straightened under chloroform and a plaster casing applied to the entire limb.
When the child is allowed to get about it should have the inner side of the sole and heel of the boot thickened to 3 inch. This keeps the strain of walking off the internal lateral ligaments of the knee-joint, and makes the child turn the toes inwards. Both these factors give assistance in preventing further development of genu valgum.
The knock-knee and bow-knee of adults do not yield to the above treatment; the splints or irons irrationally applied in these cases cannot act upon the rigid bones, and only tend to stretch the sound ligaments, but Thomas's knock-knee brace is often useful; operative procedures are essential if the deformity is to be removed.
Osteotomy by removing a wedge-shaped piece of bone from the inner side of the femur permits the long axis of the bones being brought into line. Macewen's operation is the most suitable; he chisels through the femur above the epiphysis for two-thirds of its extent and then breaks the bone across; the limb is next encased in a plaster of Paris splint after the deformity has been overcorrected and the toes turned in. Where the tibia is the chief seat of the deformity. Morton's operation is required; this consists in the removal of a wedge-shaped piece of bone from the tibial tuberosity. The deformity may often be remedied by merely
sawing through the tibia below the epiphysis; in either case the fibula must be divided or fractured (osteoclasia) if it cannot be bent. In bad cases both the femur, tibia and fibula may all require division. Bow knee is dealt with upon similar lines.
Bow-legs occur from rickets, and may be associated with the two previously mentioned deformities or exist alone. In young children the condition can usually be remedied without operation. Complete rest in the horizontal position in bed is essential. The weight of the body must be taken off the softened bones for a considerable period. Cod-Liyer Oil should be administered. the diet carefully supervised, and the nutri tion of the body improved in every possible way, while the tone of the muscles is to be assisted by massage and douching. Manipulation of the softened bones may be employed so as to assist in the reduction of the bending.
The writer believes that harm may be done by the routine adminis tration of Phosphorus when this remedy is resorted to before the bent bones have been allowed to straighten by rest and manipulation, as they are liable to become hardened in their bent position under the action of the drug.
Bandaging the limbs to suitable splints, selected as sound common sense and surgical or mechanical knowledge may dictate, will bring the deformity back to the normal standard when rest and massage fail. A double-padded splint may be placed between the legs, extending from near the perineum to some inches beyond the soles of the feet. To this splint both legs should be evenly bandaged. It is a good practice to resort to splints, even in mild cases, since their use enables the child to be safely carried or driven out in the open air without the risk of his leaning his weight upon the limbs. Standing should be rendered im possible by the adjustment of the splints. Massage and douching may be performed at night and in the morning. In severe cases attempts may be made to straighten the limb under chloroform, and in confirmed, long-standing cases osteoclasia or fracture of the bone or osteotomv is the only available procedure.
When this deformity persists in spite of these remedies Jones performs the operation of osteoclasia, using his own osteoclast for the purpose. After breaking the bones at the seat of maximum deformity. the limb is put in splints for a fortnight, and at the end of this time. after manipula tion into the-best possible position, in plaster of Paris.