Journal of Medicine and Surgery

A JOURNAL PUBLISHED MONTHLY IN THE INTEREST OF
MEDICINE AND SURGERY

VOL. XVII. TORONTO, FEBRUARY, 1905.

Original Contributions.

NO. 2.

THE ORTHOPEDIC TREATMENT OF DEFORMITIES AND DISABILITIES RESULTING FROM PARALYSIS.*

BY B. E. MCKENZIE, B.A., M.D., TORONTO.

EVERY joint should be able to maintain easily a condition of balance. If at the knee the quadriceps extensor be paretic or completely paralyzed, while the hamstring muscles still retain their contractile power, the knee will soon assume a condition of permanent flexion. It will be impossible to extend the leg so that it may functionate properly in supporting the body weight.

Another condition at the knee, which is not seen nearly so frequently, is that of hyperextension when the hamstring muscles are greatly disabled through paralysis, and the extensor muscles still retain a fair proportion of their normal strength. This is shown well in Fig. 1, where the knee is hyperextended through paralysis of the flexors.

If in the ankle the anterior group of muscles be naretic, while their antagonists retain their normal power, a condition of equinus will result (Fig. 2), the heel being drawn upward, while the anterior portion of the foot drops downward so as to interfere with the normal movement. In a similar way, if the peronei muscles be disabled, the internal group, namely, the tibiales and the long extensors, will draw the foot inward so as to bring about a condition of varus and supination. This is shown in Fig. 3, left foot.

*Read at the Meeting of the Toronto Medical Society, November 24, 1904.

A very troublesome condition of flatfoot also results when the internal group of muscles is weak, permitting the foot to assume a condition of pronation, as seen in Fig. 4, right foot.

The disability experienced by a patient suffering from paralysis is not due alone and directly to lack of muscular power, but results partly from violation of the law of balance which has just been referred to. If some plan be employed so as to maintain a condition of balance, the efficiency of the part will be greatly increased, and the discomfort and disability much relieved. The

essential object in view in the treatment of such cases is to maintain this position of balance.

The most common cause of this condition of lack of balance is anterior poliomyelitis. It results also, though less frequently, from congenital disproportion between the parts which normally should maintain the balance, from traumatism and from other forms of paralysis. One of the marked characteristics, of the common infantile spinal paralysis is that groups of muscles which act together functionally are most disabled; while one group of muscles at the knee may be affected none or little, their

opponents may be greatly disabled. The same is true of the varying groups of muscles at other joints.

Treatment. During the first few weeks after the onset of the paralysis much may be done by the use of massage and electricity. It is seldom, however, that the patient is seen at this time by the surgeon. He sometimes sees the patient before deformity has resulted, and it becomes his duty to prevent its occurrence. More frequently, however, deformity is added to the disability, and the continued use of the limb and the lapse of time

increase the amount of the deformity, as will be seen by reference to Fig. 3. In this case the weight bearing upon the feet, which are already so displaced as to be unable to support the weight of the body, will carry them further and further away from their normal position.

Before the occurrence of deformity, or even when deformity of a moderate degree has occurred, mechanical appliances may often be used with great advantage. The most generally required, and among the most effective of these, may be found in boots which are properly constructed. A child who suffers from infantile paralysis, affect

ing the inner group of muscles at the ankle so that the foot becomes greatly everted in weight-bearing (as in Fig. 3, right foot), may have a boot so constructed as to be able to hold the foot in the normal position. This not only serves to benefit the child while it is worn, but it also holds the foot in a corrected form while growth occurs, so as to prevent the extreme deformity which would result if the foot were not held in place.

Similarly, if the outer group of muscles be paralyzed so that the foot becomes inverted (as in Fig. 3, left foot), then, if seen at an early stage, a boot may be so made as to prevent the foot from becoming supinated. In cases where the tendency to turn over is very marked, a boot alone will not suffice to hold the foot directly in the line of weight-bearing. A brace, consisting of a bar at the outer

side, when the tendency is toward pronation, or at the inner side, when the tendency is toward supination, may be employed. A strap should then be fastened, in the case of pronation, to the inner side of the boot, and pass about the bar at the outer side of the leg, or be placed upon the outer side of the ankle and be carried around the bar at the inner side of the leg, when the tendency is toward supination. Such simple means prove very effective in retaining the foot directly under the body weight. In a similar manner, a night brace may be employed to hold the

foot in the correct position. The use of such a simple brace at night is of vast importance. It is probable that the deformity which results in many cases occurs more during the night than when the patient is walking about in the day-time. There are some conditions such that the weight of the body tends to hold the foot in the correct position instead of disturbing its balance. While lying in bed, however, and the weight of the bed-clothes is resting upon the anterior part of the foot, deformity frequently occurs, and a very simple brace holding the foot in the correct position during the night causes but little inconvenience to the patient and is a very marked agency in preventing deformity.

In such a case as that shown in Fig. 1, where the knee is hyperextended, a brace extending from the boot to the perineum, and having an automatic lock corresponding to the knee-joint, may be employed. This automatic lock holds the leg in extension in walking, so that the limb, which otherwise would be unable to bear the patient's weight, can do so with security.

It is not practicable here to describe all the different forms of disability which might result. The foregoing illustrations are selected from those which occur most frequently, and will serve to illustrate the mechanical means which may be employed at the different joints according to the indications.

One important distinction, however, should be pointed out. The upper extremity is employed in fine and delicate work. It