It must be emphasised that no operation should be performed in these cases until the question whether it be possible or not to restore the apparently paralysed muscle is settled. The clinical test of the recoverability of a muscle is to keep it for a long period--six or even twelve months--in a condition of relaxation. This test should be made, no matter how many months or years the muscle may have been paralysed.
The first stage in the treatment, therefore, is the correction of existing deformity, after which the limb should be kept immovable until the ligaments, muscles, and even the bones have regained their normal length and shape. The slightest stretching of a muscle which is in process of recovery disables it again.
The age of the patient influences the method of treatment. In young children in whom the structures are soft and yielding, gradual correction of the deformity is to be preferred to the more rapid methods employed in older children. The proper sequence consists in correcting the deformity, providing the simplest apparatus to keep the limb in good position, preventing erroneous deflection of body weight during walking, and then allowing the child to grow and develop until he has reached the age of five before considering such an operation as transplanting tendons, and the age of ten before deciding to ankylose a flail-like joint.
_Reposition, Manipulations, Supports._--An attempt is made to correct the deformity by manipulation, and the proper attitude is maintained by a mechanical support. If the foot has become rotated so that the sole looks laterally, the medial side of the boot must be raised, and an iron worn which extends from the knee down the lateral side of the leg, to end, without a joint, in the heel of the boot. In pes equinus, the iron is let into the back of the heel and extends forwards into the waist of the boot, to keep the foot at right angles to the leg and to relax the weak extensor muscles.
_Division of Contractions._--Bands of fascia and contracted tendons which prevent correction of deformity may have to be divided or lengthened. This is best done by the open method.
_Removal of Skin._--To assist in maintaining the desired attitude, Jones recommends the plan of excising an area of the redundant skin on the weaker aspect of the limb; in equinus, the skin is taken from the dorsum; in equino-varus, from the front and lateral aspect of the foot. When the edges of the gap have united, the foot is maintained in the desired attitude for some months, even if parents carelessly remove the iron support to let the child run about.