"Nutcracker" Treatment of Clubfoot
Hugo A. Keim, MD, and Gordon W. Ritchie, MD, Winnipeg, Manitoba
Over the past 25 years 110 children with
151 "flat-top" tali have been patients at
the Shriners Hospital in Winnipeg. Sev-
enty-seven children with 112 flat-top tali
have presented with clubfoot deformities.
The average age on admission was 3 years
and 4 months. The flat-top talus is iatro-
genic in most cases and is the direct result
of the "nutcracker" treatment of clubfoot.
This mechanism exists because upward
pressure is exerted by the manipulating
physician on the child's forefoot to correct
equinus and inversion of the foot. This
results in severe pressure exerted on the
body of the talus, since this bone acts as
the fulcrum or "nut" between the longer
forefoot and the tight achilles tendon,
causing a flat-top talus in the victim of
this treatment.
THE PRESSURES GENERATED at the ankle
are a combination of body weight plus me¬
chanical factors, both static and dynamic, trans¬
mitted through the superior surface of the talus.
This bone, because of its structure and position,
can support all the force exerted on it not only
by
body weight from above but by resistance of the
ground from below.
The normal talus has a smooth, convex carti¬
laginous articular surface receiving its nutrition
from synovial fluid through imbibition during nor¬
mal joint movements. This nutrition depends upon
intermittent compression of the joint surfaces.1
Abnormal position or any strain on the ankle joint
which interferes with this normal process of nutri¬
tion leads to destructive changes. Under certain
conditions and in pathological states such as club¬
foot or polio, the bony structures may be weakened
by immobilization and subsequent osteoporosis,
making the articular surfaces susceptible to the
compressive forces; these are often sufficient to
cause the superior surface of the talus to collapse
and flatten leading to the 'flat-top" talus.
Dr. Keim was a resident in orthopaedic surgery and Dr. Ritchie is a
on the staff of the Shriners Hospital for Crippled Children.
radiologist
Dr. Keim is presently a resident in orthopaedics at Wesley Memorial
Hospital, Chicago.
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Materials and Methods
At the Shriners Hospital for Crippled Children,
Winnipeg Unit, there have been 151 cases of flat¬
top talus in 110 children over the past 25 years. As
can be seen from the Table the great majority of
these children had club-foot deformities (talipes
equinovarus ). Of the 77 children with clubfoot,
35 had bilateral involvement, totaling 112 flat-top
tali. Poliomyelitis accounted for the second largest
group with 20 cases in 20 children, indicating their
unilateral nature. Three children with arthrogry-
posis ( amyoplasia congenita ) had bilateral involve¬
ment, and there were two cases of achules tendon
trauma with equinus deformity and resultant flat¬
top tali.
Classification.—Flat-top talus has been classified
into degrees using the following criteria visible in
the lateral radiograph (Fig 1).
Mild.—The superior surface of the talus loses
some of its convexity, but the body retains most
of its height.
Moderate.—The convex surface is lost and may
even be concave with a definite loss of body height.
Severe.—The convex surface is badly compressed
or concave with a marked loss of body substance
which is reduced 50% or more. There may be asso¬
ciated changes in the tibia and subtalar joint.
Method of Treatment—The 77 children with
clubfoot were treated with adhesive taping, Denis-
Browne splints, manipulation under anesthesia, and
various surgical procedures. Children were seen
at all ages from birth to 16 years of age, with an
average age on admission to the Shriners Hospital
of 3 years and 4 months. Most children received
prior treatment. However, several presented in
their teens with untreated congenital clubfoot
deformities (Fig 2).
Comment
Flat-top talus is usually seen in cases of treated
clubfoot. Since most of these cases are initially
seen and often treated by the family physician it
may be rewarding to review the history of the treat¬
ment of clubfoot and to speculate on its role in
the etiology of the "flat-top" talus.
 Some of the mile¬
stones in the treat¬
ment of clubfoot in¬
clude the use of a
boot-shaped device in
1641 by Fabricáis
who coined the term
"pes distortus" for this
deformity. Later, in
1782, achilles tenot-
omy was being prac¬
ticed by Lorenz,
while Cheselden was
advocating manipula¬
tion and taping. By
1836, Guerin had be¬
gun corrective ban¬
daging with plaster."
Hugh Owen Thomas
popularized manipu¬
lation in 1886 by the
invention of his
wrench which be¬
came universally ac¬ Fig 2.—Untreated clubfoot in 10-year-old child. Although
foot is greatly deformed, superior surface of talus is nearly
cepted (Fig 3). '"Al¬ normal.
though as early as
1892 Taylor advocat¬
ed less vigorous treat¬ Shriners Hospital Series
ment, it was not until Number of Number of
1935 that Kite report¬ Children "Flat-Top"
Condition
ed the method of gen¬ Congenital clubfoot* . 77
Tali
112
tle and gradual cor¬ Poliomyelitis . 20 20
rection with wedging Cerebral palsy . 4 6
Arthrogryposis (Amyoplasia congenita) 3 6
plaster casts.5 Congenital absence of fibula .
....

2 2
It is significant that Trauma achules tendon
(Equinus deformity)
in untreated clubfoot . 2 2
Charcot-Marie-Tooth
the articular surface (Hereditary muscular atrophy) . 1 1
of the talus is usually Diastematomyelia . 1 1
Total 110 151
well-maintained. Set¬ .

''Includes
tle, in 1963, reported seven cases {ten feet) due to spina bifida.
on 16 dissected speci¬
mens of untreated
clubfoot. Although
there were adaptive
changes in the bones
of the hindfoot be
Fig 1.—Classification of "flat¬ found that ". the
. .

top" talus—fop, mild, cen¬

ter, moderate, bottom, severe.
body of the talus and
particularly the part
which articulates with
the tibia were most nearly normal."G
The concept that the flat-top talus is iatrogenic
and the result of clubfoot treatment, especially by
forceful manipulation, is gradually being recog¬
nized. Colburn recently reported 21 cases of flat-top
talus in recurrent clubfoot.7 Garceau has for years
advocated early surgical correction of the equinus
deformity by release of the tight achules tendon.8'9
"Nutcracker" Mechanism.—The foot is readily Fig 3.—Thomas wrench, invented in 1886, exerted severe,
recognized as being composed of lever arms with crushing forces to foot and ankle.

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Fig 4.—"Flat-top" talus in victim of "nutcracker" treatment.
the talus acting as the fulcrum. The forefoot being
longer than the hindfoot has a greater mechanical
advantage depending on its length. The hindfoot
is tethered by the extremely strong achules tendon.
An upward force applied to the forefoot by the
physician in the treatment of a clubfoot causes a
"nutcracker" effect on the talus. The tibial shaft
and the forefoot are the arms of the nutcracker.
The binge or pivot is the achilles tendon anchored
in the calcaneus; the "nut" is the talus (Fig 4).
If the tibiotalar joint is held fixed and the phy¬
sician pushes upward on the end of the foot at the
heads of the metatarsals, the talus resists both the
thrust exerted by the doctor and the counter¬
balancing upward pull of the achilles tendon.
An example of the pressures exerted on the sur¬
face of the talus in a very small child with a fore¬
foot only two inches long and a hindfoot of one
inch can be mathematically demonstrated by mea¬
suring the "moments" acting on the foot. If the
manipulating physician exerts an upward force on
the forefoot of only 25 lb, the achilles tendon also
pulls upward due to its anchoring mechanism and
can be calculated to be 50 lb. The total force acting
on the surface of the talus then amounts to 75 lb,
roughly, a 3:1 ratio. In reality these figures are
greatly underestimated since it is possible for the
physician to generate an upward thrust of over
100 lb depending on the size of the physician, his
training, and his emotional state during manipula¬
tion. This would cause a pressure on the talus in
excess of 300 lb!
From this example it is seen that a seemingly
small force at one end of a lever arm such as the
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forefoot can result in a very large compressive
force on the surface of the talus—in some cases
large enough to crush it! Obviously the longer the
lever arm, the greater will be the compressive force.
In cases of polio or other neuromuscular diseases
where manipulation has not necessarily been car¬
ried out it is easy to see how any severe force on
the osteoporotic bone, such as a fall or misguided
step, can cause sufficient compression to collapse
the talus, especially in the presence of a tight heel
cord, through the nutcracker effect.
In order to weaken the effect of the nutcracker
the simplest procedure is to loosen the hinge or
pivot—the achilles tendon. If this is done the nut¬
cracker loses its effective force and cannot "crack"
the nut. Early tenotomy is a simple and effective
procedure and can be done subcutaneously at one
level in infants or at three levels in older children.
However, the real lesson to be learned is that
manipulations, especially on an anesthetized child,
must be done with utmost gentleness and in stages;
maximum correction should not be attempted in
one sitting. If any soft tissue ( achilles tendon or
deltoid ligament) prevents correction it should be
surgically released rather than risk crushing the
talus, causing a greater problem after manipula¬
tion than would occur without treatment. It is
obvious that in many cases early surgery is the
conservative treatment in these children.
The words of Perkins, "Manipulation must be
. .
dene ruthlessly and should only stop short of split¬
.
ting the skin,"
lu
recorded as recently as 1961
were
and should be forever blotted from our memories.
Instead let us rather remember the dramatic forces
possible in manipulations in order to avoid the
nutcracker mechanism.
1820 Foster Ave, Chicago 60610.
References
1. Trias, A.: Effect of Persistent Pressure on Articular
Cartilage, J Bone Joint Surg (Amer) 43B:376-386 (May)
1961.
2. Howorth, M.B.: Textbook of Orthopaedics, Colling-
dale, Pa: Dorman Printers, 1959, pp 426-428.
3. Thomas, H.O.: New Wrench for Club Foot, Provincial
Med J 5:286-287, 1886.
4. Mercer, W.: Orthopaedic Surgery, London: Edward
Arnold Ltd, 1959, pp 56-59.
5. Kite, J.H.: Treatment of Congenital Clubfoot, Surg
Gynec Obstet 6:190-200 (Aug) 1935.
6. Settle, G.W.: Anatomy of Congenital Talipes Equin-
ovarus: Sixteen Dissected Specimens, J Bone Joint Surg
(Amer) 45A:1341-1354 (Oct) 1963.
7. Colburn, R.C.: Flat Talus in Recurrent Clubfoot, J
Bone Joint Surg 44A:1018 (July) 1962.
8. Garceau, G.J.: "Talipes Equinovarus," in Reynolds,
F.C., ed.: Instructional Course Lectures (The American
Academy of Orthopaedic Surgeons, St. Louis: C.V. Mosby
Company, 1955, vol 12, pp 90-100.
9. Garceau, G.J.: "Congenital Talipes Equinovarus," in
Reynolds, F.C., ed.: Instructional Course Lectures (The
American Academy of Orthopaedic Surgeons), St. Louis:
C.V. Mosby Company, 1961, vol 18, pp 178-183.
10. Perkins, G.: Orthopaedics, London: The Athlone
Press, 1961, p 585.