152 CLINICAL APPLIED ANATOMY. 



common compound or secondary form of club-foot occurring 

 congenitally. The heel is raised, and the foot, particularly in 

 front of the transverse tar sal joint (that is, the combination of the 

 two joints between the astragalus and os calcis posteriorly and the 

 navicular and cuboid anteriorly) is turned inwards. The tendons 

 which are taut are the tendo Achillis behind, inducing the equinus, 

 and the tibialis anticus, tibialis posticus, together with the flexor 

 longus digitorum and flexor longus hallucis on the inner side, 

 inducing the varus. On the outer aspect of the foot the anterior 

 end of the os calcis becomes very evident, and not infrequently 

 the external surface of the neck of the astragalus can be readily 

 felt. The head of the astragalus looks somewhat inwards, 

 because the neck is markedly elongated on its outer aspect and 

 shortened on its inner. The external malleolus is prominent, 

 while the internal malleolus may be somewhat buried. A well 

 marked vertical furrow may be seen on the inner side of the foot, 

 indicating the transverse axis at which adduction and internal 

 rotation has occurred, while on the outer side after the child has 

 commenced to walk, a callosity and even an adventitious bursa 

 may be formed. 



It will thus be seen that in the treatment of these cases, if the 

 tendons which are contracted can be stretched and the anterior 

 part of the foot abducted and externally rotated, a cure may 

 be effected. Forcible manipulation and massage commenced 

 immediately after birth will in a large number of cases lead to a 

 restoration of position by obtaining the above results. The 

 equinus as a rule is more difficult to correct than the varus by 

 these manipulative procedures. 



Should the case, however, be one in which the correction of 

 the deformity has been imperfect, or, if the patient is not seen 

 until the parts have become considerably fixed, certain tenotomies 

 are needful. The tendons most commonly requiring division are 

 those of the tibialis anticus and posticus and the tendo Achillis. 

 It is desirable that the division of these tendons should be done 

 in the following order : the tibial tendons first and the tendo 

 Achillis last, so that after division of the tibials the tendo Achillis 



