The diagnosis of club-foot is not difficult. The rigid fixation differ entiates it from the not infrequent supinated foot of the newborn as well as the club-foot acquired later.
Muscular disturbances caused by paralysis and eicatricial contrac tions resulting from injuries may produce club-foot positions; but the fixation is never as typical and pro nounced as in congenital club-foot.
The history will differentiate it from similar affections.
The treatment of congenital club-foot depends entirely on the degree of deformity and whether it exists in newborn or walking chil dren. The social environment of the child is a factor in the treatment, as minute attention and care are essential in the protracted bloodless treat ment of this condition. Orthopedic dispensaries can show what harm may be done by the neglect of ignorant parents. In ease the child can be kept in a hospital for the necessary time, or can receive careful, intelligent nursing at home, the early treatment of club-foot by the von Oettingen-Fink method is very efficient.
This treatment is preferable to the vague suggestions of other authors, which so often consist in simply telling the mother that she should attempt to overcome the trouble by correcting the faulty attitude by daily massage. Before applying the von Oettingen-Fink bandage treat ment I always attempt to mould the foot into a normal position with out anesthesia. The os ealeis is grasped with one hand while the other corrects the adduction of the front part of the foot. The malleoli are then held firmly and the foot pronated with lever-like motions. Special care should he taken to place the heel in a pronated position. Finally the egninus position is corrected, which can be easily accomplished with out tenntomy in the newborn. t the same time the heel should be pulled downward the correction not done exclusively in Chopart' joint. The foot, having been made limber after various movements, is then encased in a von Oettingen-Fink paste bandage. The thigh, leg, and foot are painted with the paste,' over which the bandage is applied in the following manner: A soft bandage is fastened around the middle part of the pronated foot, starting from the outer border of the small toe, passing over the dorsum and running, across the sole, thus enabling the foot to be strongly pronated by traction (Fig. 531)). From the over-pronated foot the bandage takes its course along the leg up to the knee, which is flexed at right angles, and thence to the lower third of the thigh. It then runs along the popliteal space to the outside of the leg and ter minates after several spiral turns at the inner border of the foot. Similar traction, but somewhat distal to the first so as to include the great toe, is now made in order to increase pronation.
This bandage runs parallel to the first up to the thigh, where it is fastened and then turned back again along the leg in spiral turns to the inner border of the foot, including the heel, ending finally at the thigh above the knee and in front of the first bandage. The bandage (Fig. 53c) is finally fixed by several circular turns. It must not he applied too tight so as to produce anuemia or too much stasis. If there are points of pressure, small cotton pads may be inserted around these points. The bandage should be protected against wetting by using Billroth's batiste pads. These can be changed in one or two days or renewed by the mother when necessary. The
foot must constantly be held in an overcorrected position when the bandage is renewed. At the time of renewal the skin should be cleansed and stimulated.
The advantage of this treatment lies in the exceedingly simple technic. Fairly intelligent mothers are kept at our clinic and taught the methods of treatment, and supervision of their work later on from time to time is all that is necessary. Perseverance is essential in this method of treat ment and nearly normal conditions will he found within several months. It is much better for this treatment to be carried on in the hospital.
always first perform full overrorrertion of the deformity. because pain inflicted but ones is better than a eontinuous annoying traction. Von Oettingen suggests applying a rubber bandage in the after-treat mem, similar to the turns of the bandage around the foot and thigh and retain ing the leg in a rectangular position. Fink applies for this purpose an apparatus equipped with elastic hands. This consists of a small piece which is used as a solo and to which the foot is attached. The elastic bands to correct the prorated position of the foot, drawing it towards a bandage applied towards the thigh. At our clinic the after treatment consists in using small shoes made of celluloid and modeled from a cast taken of the feet in a pronated position. These are equipped with a band around the heel in order to check and prevent its protrusion. This method of applying the paste bandage is available only in the new born and in such cases where favorable environments and intelligent nursing can be ensured. In older cases the resistance is so marked that the encircling bandage is ineffective, either in reducing the foot or in case of successful redressement, in retaining the foot in the proper position. The continuous flexion of the knee in older children produces discomfort which they try to overcome by using their lower extremities in a more energetic manner. The moulding redressement of Lorenz is the most suitable treatment for these eases. This consists in correcting the posi tion and holding it by a plaster-of-Paris bandage. The moulding redresse ment is performed as in the newborn, but it consumes more time and strength, but it should not be abandoned until all obstacles are over come. If the shortened plantar fascia presents much difficulty an incision should be made with a tenotome. A total dorsal flexion can be procured by a tenotomy. Two incisions are made with a tenotome, one on the median, the other on the lateral side in the tendo Achillis about two centimetres apart and cutting about half through the tendon. The longitudinal fibres are separated by manual pressure and the tendon is thus elongated without being entirely divided. Total redressement of the club-foot should always precede the tenotomy, as otherwise all resistance would be lacking when an attempt at rcdressement is made. The plaster of-Paris bandage is applied with the foot in an overcorrected position, and then cut open along the instep, after hardening, in order to prevent pressure sores. The first bandage remains in position from three to four weeks. A second, and in difficult cases a third, bandage is applied until the deformity is entirely overcome (Figs. 54b, 55b).