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Proper use of the Denis Browne splint
648
The Journal o[ P E D I A T R I C S
Letters to the Editor
PIvper use of the Denis Browne splint
To the Editor: T h e state of the problem of how to care for the child who tends to invert his feet has compelled us to write our thoughts on the matter. Thousands of children have a tendency to turn their feet inward. I n the clays before the Denis Browne splint, a n d before young mothers watched t h e i r children's development quite so anxiously, this condition was disregarded, and invariably the children reached adulthood with no deformity. How many of today's adults walk pigeon-toed ? It is our recollection that the original Denis Browne splint was created for the definitive t r e a t m e n t of a true clubfoot, t h a t is, a rigid equinus metatarsus varus. About 10 years ago, a theory was p r o p o u n d e d that inversion of the foot was due to a n inward torsion of the lower end of the tibia. Numerous pediatricians and orthopedists uncritically assumed that every child who was b o r n with a tendency to m a i n t a i n the foot in a n inverted position was a victim of this deformity. As a means of correcting it, the poor infant was punished by being forced to wear the Denis Browne splint. M o r e unnecessary and expensive was the practice of placing the infant in a plaster cast for a n u m b e r of months. It is an extremely rare child who is b o r n with an inversion of the lower end of the tibia. Usually children b o r n with this inversion of the feet are merely suffering from a n inbalance of the nmscles in which the invertors of the forefoot are more active t h a n the evertors thus causing the appearance of lnetartarsus varus. Even casual examination of the feet would show that this is not a rigid deformity a n d can be overcome easily by. merely b r i n g i n g the forefoot over. Even on the assumption that there is a n actual rigid inversion deformity of the lower
end of the tibia, we cannot c o m p r e h e n d how the Denis Browne splint could correct it since no actual pressure is being" exerted or/ the deformed tibia, but the entire lower extremity is being rotated externally at the hip joint. It is a very simple procedure to d e t e r m i n e w h e t h e r or not the deformity of so-called metatarsus varus is fixed or flexible. T h e right heel is grasped with the left h a n d a n d the middle and index fingers are placed against the calcaneo cuboid joint. Using this point as a fulcrum, the examiner then grasps the forefoot between the t h u m b and index fingers of the right hand. For the left foot, the position of the hands is reversed. It should then be possible to bring the entire metatarsus over into abduction and eversion with practically no effort. W e do not think it is necessary to subject the child to x-rays to determine the angle of deformity since this procedure suffices. Should there be resistance of the foot, then x-ray would be indicated to d e t e r m i n e whether or not deformity of the tarsal and metatarsal bones is present, or w h e t h e r the ligaments a n d muscles are contracted. I t is the rigid foot which requires repeated corrective plaster casts, with subsequent use of a Denis Browne splint. We do not think that the use of a Denis Browne splint attached to the shoe is adequate to maintain correction since the shoe does not fit snugly over the region to be corrected. We adhere to the original use of the Denis Browne splint in which it was a t t a c h e d to the foot by means of adhesive strapping. I t has been our personal experience that an infant b o r n w i t h flexible inversion of the foot requires no definitive treatment. T h e t r e a t m e n t should be directed to the mother, who should be instructed to have confidence in n a t u r e and be patient until the child has acquired sufficient
Volume 61
Number 4
coordination to be able to control the muscle action of the feet in the proper manner. She should be impressed with the fact that acquisitioa of coordination is a slow process and the chiId may walk pigeon-toed in a varying degree from 1 to 3 years. T h e majority walk normally in a shorter time. I n order to make the m o t h e r feel that something is being done, it has been our custom to instruct the mother to turn the
Letters to the Editor
649
child's foot to an outward position as described above, every time she changes the diaper. It is our firm belief that the use of a Denis Browne splint in cases with flexible feet is of n o value and should be discontinued. HYMAN
SOIFER,
M.D.
P H I L I P PALEW~ M.D.
The Journal o[ P E D I A T R I C S
Letters to the Editor
PIvper use of the Denis Browne splint
To the Editor: T h e state of the problem of how to care for the child who tends to invert his feet has compelled us to write our thoughts on the matter. Thousands of children have a tendency to turn their feet inward. I n the clays before the Denis Browne splint, a n d before young mothers watched t h e i r children's development quite so anxiously, this condition was disregarded, and invariably the children reached adulthood with no deformity. How many of today's adults walk pigeon-toed ? It is our recollection that the original Denis Browne splint was created for the definitive t r e a t m e n t of a true clubfoot, t h a t is, a rigid equinus metatarsus varus. About 10 years ago, a theory was p r o p o u n d e d that inversion of the foot was due to a n inward torsion of the lower end of the tibia. Numerous pediatricians and orthopedists uncritically assumed that every child who was b o r n with a tendency to m a i n t a i n the foot in a n inverted position was a victim of this deformity. As a means of correcting it, the poor infant was punished by being forced to wear the Denis Browne splint. M o r e unnecessary and expensive was the practice of placing the infant in a plaster cast for a n u m b e r of months. It is an extremely rare child who is b o r n with an inversion of the lower end of the tibia. Usually children b o r n with this inversion of the feet are merely suffering from a n inbalance of the nmscles in which the invertors of the forefoot are more active t h a n the evertors thus causing the appearance of lnetartarsus varus. Even casual examination of the feet would show that this is not a rigid deformity a n d can be overcome easily by. merely b r i n g i n g the forefoot over. Even on the assumption that there is a n actual rigid inversion deformity of the lower
end of the tibia, we cannot c o m p r e h e n d how the Denis Browne splint could correct it since no actual pressure is being" exerted or/ the deformed tibia, but the entire lower extremity is being rotated externally at the hip joint. It is a very simple procedure to d e t e r m i n e w h e t h e r or not the deformity of so-called metatarsus varus is fixed or flexible. T h e right heel is grasped with the left h a n d a n d the middle and index fingers are placed against the calcaneo cuboid joint. Using this point as a fulcrum, the examiner then grasps the forefoot between the t h u m b and index fingers of the right hand. For the left foot, the position of the hands is reversed. It should then be possible to bring the entire metatarsus over into abduction and eversion with practically no effort. W e do not think it is necessary to subject the child to x-rays to determine the angle of deformity since this procedure suffices. Should there be resistance of the foot, then x-ray would be indicated to d e t e r m i n e whether or not deformity of the tarsal and metatarsal bones is present, or w h e t h e r the ligaments a n d muscles are contracted. I t is the rigid foot which requires repeated corrective plaster casts, with subsequent use of a Denis Browne splint. We do not think that the use of a Denis Browne splint attached to the shoe is adequate to maintain correction since the shoe does not fit snugly over the region to be corrected. We adhere to the original use of the Denis Browne splint in which it was a t t a c h e d to the foot by means of adhesive strapping. I t has been our personal experience that an infant b o r n w i t h flexible inversion of the foot requires no definitive treatment. T h e t r e a t m e n t should be directed to the mother, who should be instructed to have confidence in n a t u r e and be patient until the child has acquired sufficient
Volume 61
Number 4
coordination to be able to control the muscle action of the feet in the proper manner. She should be impressed with the fact that acquisitioa of coordination is a slow process and the chiId may walk pigeon-toed in a varying degree from 1 to 3 years. T h e majority walk normally in a shorter time. I n order to make the m o t h e r feel that something is being done, it has been our custom to instruct the mother to turn the
Letters to the Editor
649
child's foot to an outward position as described above, every time she changes the diaper. It is our firm belief that the use of a Denis Browne splint in cases with flexible feet is of n o value and should be discontinued. HYMAN
SOIFER,
M.D.
P H I L I P PALEW~ M.D.