Lower Limb Disorders Part 2 PDF

Lower limb disorders Part 2 Prof Dr/ Anwar Ebid Lower limb disorders Classification Fractures Of The Femur Fracture of the neck of the femur Fracture of the trochanteric region Fracture of the shaft of the femur Supracondylar fracture Condylar fracture INJURIES OF THE KNEE Fractures of the patella I...

Lower limb disorders Part 2 Prof Dr/ Anwar Ebid Lower limb disorders Classification Fractures Of The Femur Fracture of the neck of the femur Fracture of the trochanteric region Fracture of the shaft of the femur Supracondylar fracture Condylar fracture INJURIES OF THE KNEE Fractures of the patella Injuries of the extensor mechanism Dislocation of the knee joint Dislocation of the patella Injuries of the ligaments of the knee Tears of the menisci of the knee Traumatic effusions in the knee FRACTURE SHAFT OF FEMUR ✓ Fracture of the shaft of the femur occurs at any age, usually from severe violence such as may be caused by a road accident or aero plane crash. Radiographic examination. ✓ Radiographs should always include the hip and knee. ✓ A recognized error is to overlook a dislocation of the hip coexisting with a fracture of the femoral shaft. Treatment ❖ The well-tried method of conservative treatment by sustained weight traction with the limb supported in a Thomas's type splint has now been largely replaced by intramedullary nailing with interlocking screws as the method of choice of treatment. 1-Conservative treatment by traction and splintage. The principles of this method are to 1-Reduce the fracture by traction and manipulation 2-Support the limb in a Thomas's splint and 3-Maintain continuous traction by the application of a suitable weight to preserve length until healing occurs. The duration of splintage varies from case to case, Except in children, few fractures of the femoral shaft are firmly joined in 12 weeks: most take 16 weeks or even longer. When the stage of sound union is reached the splint is removed and the patient is allowed to exercise freely in bed before walking is begun. Thereafter rehabilitation is continued until full function is restored. Treatment 2-Cast or functional bracing. In appropriate cases usually those of fracture of the lower half of the femur and especially when the fracture is of the transverse or short oblique 3-Treatment by external fixation. The method is applicable mainly to open fractures with contamination or to infected fractures, in which internal fixation may be unduly hazardous. External fixation offers the advantage that any wound is easily accessible for treatment 4-Operative treatment with internal fixation. Internal fixation, usually by a long intramedullary nail, is now the accepted treatment of choice for many adult femoral shaft fractures. The advantages of early mobilization, with the reduction in the incidence of muscle wasting and joint stiffness, outweigh the slight risk of infection complicating the operation. Continuous traction with balanced suspension, using a Thomas's (or similar) splint with Pearson knee flexion attachment Functional brace with plastic knee hinges used in the later stages of treatment of a midshaft fracture of the femur. Treatment Locking screws. ✓ In recent years locking the nail in place at the upper and lower ends by the insertion of cross-screws through holes provided at each end of the nail. The locking screws prevent rotation of the nail and thus increase stability. Post-operative treatment. ✓ If it has been possible to secure rigid fixation with a strong nail of adequate diameter there is no need to immobilize the thigh in plaster or a splint. ✓ The patient may lie free in bed and practice exercises for the hip and knee joints and related muscles. ✓ Walking may be begun with the partial support of crutches 2 or 3 weeks after operation, or sometimes even sooner. Complications The following complications of femoral shaft fractures will be considered: 1) Dislocation of the hip and stiffness of knee 2) Injury to a major artery or nerve 3) Infection. In cases of open (compound) fracture 4) Delayed union. Four months is a fair average time for union of a fractured femoral shaft in an adult. 5) Non-union. If union fails to occur and the fracture surfaces are becoming rounded and sclerotic, operation should be advised. 6) Mal-union. Without constant supervision the fragments may suffer redisplacement in the form of angulations or overlap Rehabilitation ✓ Exercises for the lower leg and foot are important in preserving muscle tone and in preventing deformity especially that of equines and they should be begun immediately. ✓ As soon as the initial pain of the fracture begins to settle usually about 1 week after the injury active quadriceps and knee exercises are begun. ✓ Knee flexion through about 60° may be allowed, but more important than flexion is the ability to extend the knee fully by quadriceps action. ✓ These activities do not interfere with union of the fracture and may be encouraged with full confidence. Supracondylar fracture of femur There are 3 different types of distal femur fractures: Transverse fracture Comminuted fracture Intra-articular fracture. The fracture extends into the knee joint and damages the cartilage. Symptoms Tenderness Bruising Swelling Misshapen knee (looks out of place) Shortened or crooked leg Treatments There are nonsurgical and surgical treatments for supracondylar femoral fracture. Nonsurgical Casts and braces Skeletal traction. Surgical External fixation. Internal fixation Knee dislocation knee dislocation is an uncommon but extremely serious injury in which the thigh bone (femur) and shin bone (tibia) lose contact with each other. knee dislocation is different from a patellar dislocation in which only the kneecap is detached from its groove at the end of the femur. Symptoms 1. Visible swelling 2. Deformity of the knee joint. 3. Misalignment of lower extremity & shortening 4. Movement of the joint cause extreme pain. Complications 1. Compression or damage of the peroneal nerve that runs along the outer edge of the calf 2. Rupture or obstruction the popliteal artery and vein located at the back of the knee 3. The development of deep venous thrombosis (DVT) If a vascular obstruction is left untreated for more than eight hours, the chance of amputation is 86% compared to 11 % if treated within eight hours. Surgical treatment of knee dislocation 1-Knee Cartilage Repair A surgeon can use special tools to remove frayed and tattered cartilage and smooth the remaining cartilage surface. This contouring of cartilage reduces joint friction reduce knee pain, restore knee function and, potentially slow down future cartilage degeneration Knee debridement Knee chondroplasty is often done in conjunction with debridement 2-Knee Cartilage Replacement Osteochondral autograft transplantation uses cartilage from the patient. Osteochondral allograft transplantation uses cartilage from outside the patient, usually from a cadaver. 3-Arthroscopic surgery. This sort of surgery involves inserting a small camera into the knee joint and using a projected image to determine what damage has been caused in the knee by dislocation. 4-Reconstructive surgery. This type of procedure will typically be undertaken after arthroscopic surgery has already been performed. It may involve removing or repairing damaged cartilage, relocating a severely dislocated kneecap or repairing damaged ligaments and tendons Treatment for Dislocated Patella Most dislocated kneecaps can be treated nonsurgical, though some extreme cases may require surgical intervention. In most cases, several nonsurgical treatment options will be attempted before considering surgery to realign the kneecap. Common nonsurgical treatments for a dislocated patella may include: 1. Pain medication. 2. RICE. As a first response treatment to injury, an athlete will be advised to rest, ice, compress and elevate 3. Reduction. Sometimes the kneecap will move back into place on its own as the leg in moved. physician may try to move the kneecap manually while the leg is gradually flexed until it's straight. 4. Joint aspiration. If large amounts of excess fluid are present in the knee joint, a doctor may aspirate the joint by using a syringe to remove this fluid. If the injury has involved an open wound, then the fluid may also be used to check for infection. 5. Immobilization. To prevent the kneecap from being re-dislocated or injured, the athlete’s leg may be placed in an immobilizing cast or brace for a period. 6. Crutches. An athlete may also use crutches to reduce pressure on the knee joint and patella. Surgical treatment: Fixation by using tension band wiring or using cannulated screw Telescopic Intramedullary Nailing Telescopic intramedullary nailing is used to 1-Prevent or stabilize fractures, and 2-Correct deformities of long bones in 18 months or older children with osteogenesis imperfecta. It is also indicated in young children for long bone fracture stabilization, correction of long bone deformities, and for limb lengthening when combined with external fixator systems. Contraindications for telescopic intramedullary nailing are active infection at or near the site of osteotomy or incisions, and children at the age of skeletal maturity. Osteogenesis imperfecta (OI), also known as brittle bone disease, is a group of genetic disorders that mainly affect the bones. It results in bones that break easily. The severity may be mild to severe DISORDERS OF THE LEG and FOOT Fracture tibia Rupture of the calcaneal tendon Intermittent claudication Osteoarthritis of the ankle Recurrent subluxation of the ankle Congenital club foot Congenital talipes calcaneovalguS Fracture Tibia The shinbone or tibia is the long bone located in the lower leg between the knee and foot. Tibial fractures are common and usually caused by an injury or repetitive strain on the bone. The recovery and healing time for tibial fractures differs and depends on the type and severity of the fracture The tibia plays a key role in body mechanics, as it is: 1. The larger of the two lower leg bones 2. Responsible for supporting most of the body weight 3. Vital for proper knee and ankle joint mechanics Types and causes of tibia fracture The tibia can have the following types of fracture: 1. 2. 3. 4. 5. Stable fracture. This is called a non-displaced fracture. Displaced fracture. Surgery is often needed to correct this type of fracture and realign the bones back together. Stress fracture. Stress fractures, also called hairline fractures, are common overuse injuries. These fractures are small, thin cracks in the bone. Spiral fracture. When a twisting movement causes a break, there may be a spiral-shaped fracture of the bone. Comminuted fracture. When the bone fractures into three or more pieces, this is called a comminuted fracture. Cause of tibia fractures Traumatic injuries, such as motor vehicle accidents or falls Sports that involve repeated impact to the shinbones, such as long-distance running Injuries from contact sports such as American football osteoporosis, which makes the bones weaker than usual Symptoms of tibia fracture ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Localized pain in one area of the tibia or several areas if there are multiple fractures Lower leg swelling Difficulty or inability to stand, walk, or bear weight Leg deformity or uneven leg length Bruising or discoloration around the shinbone Sensation changes in the foot Bone protruding through the skin A tent-like appearance where the skin is being pushed up by the bone Treatment of a tibia fracture depends on several factors, including Treatment ✓ Overall health at the time of the injury ✓ The cause and severity of the injury ✓ The presence or extent of damage to the soft tissues that surround the tibia. Recovery Recovery from a tibial fracture varies based on the severity of the fracture often recover within 4 to 6 months Complications Complications of a tibia fracture may include: 1. Complications from surgery or the need for further surgeries 2. Nerve, muscle, or blood vessel damage 3. Compartment syndrome, a serious condition which there is a reduction in blood supply to the leg due to swelling. More common in diaphyseal tibial shaft fractures than proximal or distal tibia fractures 4. Bone infection called osteomyelitis 5. Development of a non-union where the bone does not heal 6. Bone loss 7. Associated dislocation and fractures Case 1: undergoing external fixation and delayed open reduction and internal fixation. Preoperative Xray imaging (A, B), 3D reconstruction imaging (C, D), postoperative CT scan (E–H). Case 2 undergoing external fixation and delayed open reduction and internal fixation. Preoperative X-ray (A, B), postoperative X-ray imaging (C–F). Clinical and X-ray images of a 62-year-old female patient with VI tibial plateau fracture. Pre-operative X-rays show highly comminuted fracture (a). Fracture fixation with a 6.5 mm cannulated screw and fine-wire circular fixator (b, c). X-ray following removal of external fixation (d). RUPTURE OF THE CALCANEAL TENDON Ruptured calcaneal tendon (tendo Achilles) is often overlooked, the symptoms being wrongly ascribed to astrain or to a ruptured plantaris tendon. Pathology. The rupture is nearly always complete. It occurs about 5 centimeters above the insertion of the tendon. If it is left untreated the tendon unites spontaneously, but with lengthening. Clinical features. While running or jumping the patient feels a sudden agonizing pain at the back of the ankle. He may believe that something has struck him. He is able to walk, but with a limp. On examination ✓ There is tenderness at the site of rupture. ✓ There is general thickening from effusion of blood and from oedema, ✓ Gap can usually be felt in the tendon. ✓ The power of plantarflexion at the ankle is greatly weakened, though some power remains through the action of the tibialis posterior, the peronei, and the toe flexors. ✓ A useful test to be carried out with the patient prone, is to squeeze the bulk of the calf muscles from side to side. Normally this causes a slight plantarflexion movement of the foot, but not if the tendon is ruptured. Diagnosis. ✓The retention of some power of plantarflexion may deflect the unwary from the correct diagnosis. ✓The crucial test is to ask the patient to lift the heel from the ground while standing only upon the affected leg (Fig. 338). This is impossible if the tendon is ruptured. ✓The gap in the tendon may be well demonstrated by ultrasound scanning. The crucial test of intact calf function is to raise the heel from the ground while standing "only on the affected leg. Inability to do this after an injury to the calcaneal tendon is "diagnostic of complete rupture. Treatment ✓ Non-operative treatment by immobilization in plaster for five weeks, with the foot in slight equines to relax the tendon and thus to help to prevent lengthening. Operative treatment ✓ Repair of the tendon, preferably by nonabsorbable sutures of synthetic material, tension on the suture line being relaxed by immobilizing the limb with right-angled knee flexion and moderate ankle plantarflexion for two weeks. ✓ There is certainly still a place for operation in athletic persons, to reduce the risk of lengthening of the tendon and consequent loss of 'spring-off. ✓ For the next four weeks a below-knee plaster with the ankle at 90 degrees is worn. ✓ After removal of the plaster by increasingly vigorous exercises for the calf muscles, practiced until full strength is restored. INTERMITTENT CLAUDICATION Intermittent claudication Is a symptom of arterial insufficiency in the lower limb. In its typical form it is characterized by cramp-like pain in the calf, induced by walking and relieved by rest. Cause. ✓ The usual underlying cause is arteriosclerosis-with consequent partial or total obstruction, of the main limb vessel. Thrombo-angiitis obliterans and arterial embolism are fewer common causes. Tobacco smoking is a major contributory factor. Pathology. ✓ The basic disturbance is ischemia of muscle, in consequence of which metabolites cannot be removed speedily enough when the muscle is exercised. ✓ The accumulation of metabolites is believed to be responsible for the pain, which subsides within a few minutes when the muscle is rested. ✓ The muscles usually affected are those of the calf, but in some instances other muscle groups are involved, according to the site of the arterial obstruction. ✓ The vascular lesion is usually a complete occlusion of the femoral or the popliteal artery. ✓ In claudication affecting the buttock the aortic bifurcation or the iliac artery may be occluded Clinical features ✓ Intermittent claudication is much more common in men than in women. ✓ In the usual arteriosclerotic type, the patient is past middle life, but in cases due to thrombo-angiitis obliterans or embolism the symptoms may develop in early adult life. ✓ The patient is usually a regular smoker. ✓ With gradual arterial occlusion the onset is insidious, and the symptoms are slowly progressive; but in cases precipitated by thrombosis or embolism the onset may be sudden. ✓ In a typical case patient complains that after walking a certain distance perhaps a hundred meters or so he is forced to stop by severe cramplike pain in the calf, or occasionally in another muscle group, such as the buttock. ✓ After a few minutes' rest the pain disappears, and he can walk on again for a similar distance. On examination ✓ ✓ ✓ ✓ There is objective evidence of impaired arterial circulation in the lower limb. The posterior tibial, dorsalis pedis, and popliteal pulses are absent. There may be ischemic changes in the skin of the foot. Evidence of widespread arterial or cardiac disease is nearly always found on general examination. Investigations. ✓ Ankle pulse recordings show a low arterial pressure compared to the arm pressure, and the pressure may fall markedly on exercise. ✓ Doppler ultrasound probing and other tests may show reduced blood flow in the peripheral vessels. Radiographic features. Plain radiographs often show patches of calcification in the walls of several arteries, from the aorta downwards. Arteriography will demonstrate the site and extent of the arterial occlusion. Diagnosis. Intermittent claudication is frequently misdiagnosed. Unless a detailed history is obtained, the patient's complaint of pain in the calf may suggest to the unwary doctor the likelihood of foot strain or flat- foot. Moreover, such a diagnosis may seem to be supported by the "finding of flattened arches or deformed feet, common in the elderly. Descending aortic calcification CT scan Linear calcific areas noted along the anterior and posterior aspects of the tibia. ✓ The clues to the correct diagnosis are the typical history and the impairment of the arterial pulses, and it may be confirmed by blood flow studies, including ankle pressure recordings, Doppler ultrasound examination and, if necessary, arteriography. ✓ In Intermittent claudication from vascular disease bears a resemblance to the symptoms of spinal stenosis (pseudo claudication), but in that condition the arterial circulation is not impaired. Prognosis. The outlook is serious, though deterioration is often slow. ✓ Progressive cases increasing ischemia may lead eventually to gangrene of the foot. ✓ Peripheral vascular disease is often associated with cardiac disease; so, the general prognosis must always be guarded. Treatment. ✓ If the arterial obstruction is proximal, involving the aorta; iliac artery or common femoral artery, good results may be expected from prosthetic replacement of occluded vessels. ✓ In contrast, peripheral disease the results of arterial reconstruction are often unsatisfactory, and if the viability of the foot is not in danger and rest pain is absent, operation is usually better avoided. ✓ It is important for the patient to give up smoking. RECURRENT SUBLUXATION OF THE ANKLE When the lateral ligament of the ankle is torn and fails to heal there may be persistent instability with recurrent attacks" of giving way in which the talus tilts medially in the ankle mortise. Anterior displacement relative to the tibial articular surface may also occur. The causative injury is always a severe inversion force. Clinical features. The patient complains that the ankle 'goes over' at frequent intervals, often causing him to fall. Each incident is accompanied by pain at the lateral side of the ankle. There is always a 'history of previous " severe injury, followed by much swelling and extensive bruising at the lateral side of the joint. On examination ✓ There is often some oedema about the ankle. ✓ There is tenderness over the site of the lateral ligament. ✓ The normal ankle movements dorsiflexion and plantarflexion are unchanged, but abnormal mobility is present as shown by the fact that the heel can be inverted passively beyond the normal range permitted by the subtalar joint. ✓ Moreover, when the heel is fully inverted a dimple or depression of the skin may be visible in front of the lateral malleolus, where the soft tissues have been 'sucked' into the gap created between tibia and talus. Radiographic features Routine radiographs do not show any abnormality. Antero-posterior films must be taken while the heel is held fully inverted. If the lateral ligament is torn or lax the talus will be shown tilted away from the tibiofibular mortise at the lateral side through 20 or 30 degrees or more. Anterior displacement of the talus relative to the tibial articular surface may also be demonstrated in lateral radiographs taken while the foot is pushed forwards. Tilting of the talus in the ankle mortise under adduction stress; an indication of torn lateral ligament. Diagnosis. Chronic strain of the lateral ligament may cause similar symptoms, but in that condition, radiographs will not show the talus tilted significantly on forced inversion. (The talus may-tilt up to 15 degrees in a normal ankle.) Treatment If the disability is slight it may be sufficient to strengthen the evertor muscles (mainly the peronei) by exercises, to enable them to control the ankle more efficiently. Stability may also be enhanced by broadening " and 'floating out' the heel of the shoe. If the disability is severe, operation is required. A new lateral ligament may be constructed either from the peroneus brevis tendon or from the peroneus tertius. Trials are also proceeding with the use of artificial ligaments, either as substitutes or as a means of promoting the growth of new ligamentous tissue. OSTEOARTHRITIS OF THE ANKLE ✓ Degenerative destruction of the articular cartilage is less common in the ankle than in the knee or hip. ✓ There is nearly always a known predisposing factor which causes the joint to wear out prematurely. ✓ The commonest predisposing factor is Irregularity or mal-alignment of the joint surfaces after a fracture. Articular disease such as previous rheumatoid arthritis or osteochondromas is the primary factor. Clinical features. The symptoms are pain which slowly increases over months and years, and limp. On examination The joint is a little thickened from hypertrophy of bone (osteophyte formation) at the joint margins. Movements are restricted slightly or severely according to the degree of arthritis. Radiographs show the typical features of osteoarthritis Narrowing of the cartilage space, a tendency to sclerosis of the bone adjacent to the joint, and osteophyte formation at the joint margins Treatment In mild cases treatment is often unnecessary, because the patient may be willing to accept the disability when the nature of the trouble has been explained. When treatment is called for, conservative measures should be tried "first if the disability is only moderate. Physiotherapy By short-wave diathermy, hot baths and active exercises is usually advised, US, LASER. Sometimes local splintage by a molded polypropylene support will provide relief while allowing the patient to continue to walk Such treatment, however, is only palliative, and if the disability increases to the extent of becoming a serious handicap operation should be undertaken. This should usually be by arthrodesis, which provides a painless stable joint. Replacement arthroplasty is a possible alternative, but the longterm results are so uncertain that it is not yet widely recommended. Marked narrowing of the cartilage space and the prominent osteophytes. Bilateral club foot (talipes equino-varus) in an infant boy. Note the poor development of the calf muscles DISORDERS OF THE FOOT CONGENITAL CLUB FOOT (Talipes equino-varus) The rather vague term 'club foot' has come to be synonymous in the minds of most surgeons with the commonest and most important congenital deformity of the foot talipes equino-varus. The less common, and usually less serious, form of club foot, talipes calcaneo-valgus, will be considered later under that title. Cause. ✓ In most cases a defect of foetal development is responsible, with imbalance between the invertorplantar-flexor muscles and the evertor-dorsiflexor muscles. ✓ A neuromuscular defect is possibly relevant. Minor degrees of the deformity may possibly be explained by prolonged mal-position of the foetal foot in the uterus, but this cannot be accepted as the usual cause. Talipes equino-varus Pathology ✓ The crucial component of the deformity is subluxation of the talo-navicular joint. ✓ The soft tissues at the medial side of the foot are under-developed and shorter than normal. ✓ The foot is adducted and inverted at the subtalar, midtarsal, and anterior tarsal joints, and is held in equinus (plantarflexion) at the ankle. ✓ In most cases under-development of the calf and peroneal muscles is a striking feature. ✓ Thus, if only one foot is affected there is a marked discrepancy in the girth of the calf between the two sides. ✓ Clinical features ✓ The deformity is much commoner in boys than in girls. (Contrast congenital dislocation of the hip, which is much commoner in girls.) ✓ One or both feet may be affected. ✓ When the infant is born it is noticed that the foot is turned inwards so that the sole is directed medially. Component of deformity The deformity, to be more precise, consists of three elements: 1) Inversion (twisting inwards) of the foot; 2) Adduction (inward deviation) of the forefoot relative to the hindfoot; and 3) Equinus (plantarflexion). The foot cannot be pushed passively through the normal range of eversion and dorsiflexion. There may be obvious under-development of the muscles of the lower leg, especially noticeable when only one foot is affected. Diagnosis New-born infants should be examined routinely for evidence of club foot. It is not sufficient, for purposes of diagnosis, that the foot be found to rest in the position described, for often the feet of normal infants tend to lie naturally in a somewhat inverted position. The criterion for the diagnosis of club foot is that the deformity cannot readily be corrected and overcorrected to bring the foot into eversion and dorsiflexion It should be remembered that in normal infants under one year old it is possible to evert and dorsiflex the foot far enough to bring the little toe into contact with the shin. Prognosis. The prognosis depends largely uponthe age at which primary treatment is begun, and upon the efficiency with which it is carried out. The longer the delay before treatment, the smaller is the prospect of complete cure. Treatment ✓ In the past the most widely accepted practice was to rely upon conservative treatment by correction and splintage during the first year of life but in many cases the results were disappointing. ✓ All too often operation was needed later to correct recurrent deformity, and even then, the foot was far from normal. ✓ The present trend is towards operative correction in early infancy if full and lasting correction is not obtained quickly by the traditional methods of conservative treatment. Primary conservative treatment. Ideally treatment should be begun immediately after birth—certainly not more than one week later. The principles of treatment are: 1) To correct and over-correct the deformity by repeated firm manual pressure; and 2) To hold the foot in the over-corrected position to counteract the natural tendency for the deformity to recur. Maintenance of correction. Three methods are available for holding the foot in the corrected position between manipulations: 1) plaster of Paris case; 2) metal splints as advocated by Denis Browne and 3) adhesive strapping The plaster must be changed every week at first, but the interval may be extended to two and then three weeks as the child grows larger. Treatment in neglected or relapsed-cases ✓ Repeated manipulation and retention in plaster can produce worthwhile improvement in children of up to 2 years of age. ✓ If significant deformity is still present after the age of 2, operative treatment is required. ✓ The treatment concentrate to restore a plantigrade foot. Operative treatment and Types of operation The idea behind early operation is to set the tarsal bones in normal relationship to one another and to remove deforming stresses, thus allowing the bones to develop in their normal shape from an early age In children aged 2 to 12 years there is the option to employ any of six operations, depending upon the circumstances of each -case: 1) Division of the short soft tissues at the medial side of the foot, the foot thereafter being forced into a plantigrade position and immobilized in plaster for three months 2) Transfer of the tendon of the tibialis anterior to the outer side of the foot 3) Transfer of the tibialis posterior tendon through the interosseous membrane to the outer side of the foot, to supplement the action of the evertor muscles 4) Lengthening of a short calcaneal tendon 5) Arthrodesis of the calcaneo-cuboid joint, with excision of a wafer of bone to shorten the lateral border of the foot 6) When inversion of the heel is a prominent feature, osteotomy of the calcaneus with insertion of a bone wedge in the medial side to correct the line of weight-bearing In children over the age of 12 resort must be had to operation upon the 'Plantigrade = sole walking; with the sole on the ground. CONGENITAL TALIPES CALCANEO-VALGUS ✓ This is the opposite deformity to talipes equino varus. ✓ The foot is everted and dorsiflexed. ✓ It is usually a less serious deformity than talipes equino varus and with few exceptions, in which there is displacement at the talonavicular joint, it responds readily to treatment. Cause. The cause is unknown. In some cases, it may simply be a postural deformity, from folding of the foot against the shin for a long time in intrauterine life Clinical features ✓ One foot or both feet may be affected. ✓ The footrests in a position of eversion and dorsiflexion, so that its dorsum lies almost in contact with the shin ✓ Tightness of the dorsolateral soft tissues prevents the foot from being brought down easily into inversion and equinus, though with steady pressure a fair degree of correction can usually be obtained. Treatment. In most cases the deformity will respond readily to repeated manual stretching by the parents, who should be carefully instructed how to coax the foot into the over corrected position of inversion and equines.