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THE

BIRMINGHAM MEDICAL REVIEW.

JULY, 1893.

ORIGINAL COMMUNICATIONS.

ON THE TREATMENT OF TALIPES CAVUS.*

BY WILLIAM THOMAS, F.R.C.S..

SURGEON TO THE ORTHOPÆDIC HOSPITAL.

TALIPES CAVUS has received perhaps less attention from Orthopædic Surgeons than any other deformity of the foot, and in some manuals devoted to this branch of surgery it is not even mentioned. Possibly this may be due to the fact that it is rarely developed very early in life, that the deformity it gives rise to is more easily concealed, and that it is comparatively infrequent. It is often a very painful condition, interfering seriously with locomotion, and presenting difficulties in treatment quite as great as are met with in other forms of club-foot; and certainly with as great a tendency to relapse as any. I have therefore thought that a few remarks on the treatment of this deformity might lead to an interesting discussion, and that the comparison of experiences thus brought out may not be unprofitable.

In a well-marked case we find the following features:The arch formed by the tarsus and metatarsus is abnormally increased, so that the dorsum of the foot has a humped appearance; the hollow on the under surface is exaggerated, and although sometimes the outer border touches the ground it is only by incurving the foot so as to produce a certain amount of * Read at a meeting of the Midland Medical Society.

A

varus.

The metatarso-phalangeal joints are enlarged, especially that of the hallux, and the toes are flexed so that their tips only touch the ground. Callosities are usually present all along the under surfaces of the metatarso-phalangeal joints. The plantar fascia is found to be exceedingly tense, and the extension forwards of the toes in walking or standing is seriously interfered with if not entirely prevented. The deep flexor tendons are contracted and can be felt firm and cord-like beneath the plantar fascia; the muscles of the sole of the foot share in the general shortening and actively resist extension, and altogether there is a general rigidity and want of elasticity, especially when the foot is planted firmly on the ground. The tendons of the extensors draw back the flexed toes and cause the phalangeal joints to project in a manner specially adapted to produce corns. With all these conditions it is not surprising that tarsalgia should be such a frequent accompaniment, and the wonder is how the patient can walk at all.

I have never yet seen a congenital case, but have occasionally been told that the patient was born so; so that looking for the causes of talipes cavus we are met by the important fact that the condition in a large proportion is acquired, but how acquired is not very apparent; possibly the rheumatic or gouty diathesis may be a constitutional factor of importance, but ill-fitting boots which compress the toes and do not allow for proper expansion are much to blame, as by their presence the muscles of the sole of the foot contract to keep the toes from pressing forward, and the plantar fascia does not grow in proportion to the rest of the foot.

In a small proportion of cases the condition is congenital, and is sometimes considered as one of the points of blue blood. There is, however, a very marked difference between the highlyarched instep and true cavus. The former is not attended by callosities and the generally contracted state of the toes presented by the latter. There is also a decided contrast in the character of the arch in the two conditions, and the lumpiness of cavus is easily distinguished when present.