Download DIPLOPODIA WITH DOUBLE FIBULA AND AGENESIS OF TIBIA

DIPLOPODIA
WITH
DOUBLE
FIBULA
A
I. C.
From
A 14-year-old
girl
with
CASE
NARANG,
V.
the
Forces
Armed
a congenitally
R.
AND
AGENESIS
OF
TIBIA
REPORT
MYSOREKAR,
B.
Medical
and
deformed
P.
MATHUR
College,
Pune,
shortened
right
india
foot is described.
leg and
The
patient
could not bear weight on the deformed
limb and had to hop on the left leg. The deformed
foot faced
backwards
and had nine toes. The right leg was shorter
than the left by 26 centimetres.
Radiologically,
the
lower
end ofthe
right
femur
were
two
metatarsals,
the
calcanei,
one talus,
one navicular,
and all the toes had three phalanges
two cuboids
except
for
be
only
there
as we)).
attained.
by partial
duplication
on the tibial aspect.
differentiated
two or three
are
additional
tarsal
and
resembles
generally
associated
and the
According
whole
foot
to Jones,
a
with
fan.
The
therefore
Barnes
three
of whom
phalanges
condition
is
two of the children.
bizarre
combination
epiphysis
but
A
the tibia
is
of
“
double
to Jones
fibular
fibula”
configuration
are
(1978)
et a!.
do
extremely
two
not
rare
slender
and
bones
necessarily
of
represent
Laurin,
of diplopodia
Favreau
and Labelle
(1964)
with absence
of both tibiae
tion of both
fibulae.
There
calcanei.
the
cuboids
born
suggested
that
the
Mysorekar
where
there
cuneiforms,
findings
and Lohokare
were eight
of
pointed
(1970)
toes, ten
a navicular,
the
little
toes.
to a fibular
a bifid
talus
and
I. C. Narang.
MS. FICS.
Brigadier.
Commandant
B. P. Mathur,
MS. MPhiI,
Lieutenant-Colonel.
Deputy
Commandant
V. R. Mysorekar.
MSc.
PhD,
Professor
of Anatomy,
Armed
Forces
Requests
for
© 1982
British
206
healthy.
reprints
Editorial
should
be
Society
sent
to Professor
of Bone
and
V.
Joint
in
diplopodia
are
neither
associated
with
REPORT
to
1980
years
The
and
the
Artificial
with
then
All
mother
a
Limb
congenitally
had
four
College.
leg and
only
one
other
toes
foot
faced
Limb
Centre,
Pune-41
elder
taken
during
examination
leg had
five
having
the
no
learnt
out of seven
any
the
on
children
and
both
was no
drugs
or
pregnancy.
patient
systemic
to hop
brothers
Her grandparents,
normal.
There
illness
were
right
right
her
normal.
were
febrile
general
being
Artificial
J
Medical
her
There
there
and
parents.
any
the
from
a
there
structures.
absent
of the tibia. The anatomical
foot are also presented.
June
of nine
of
deformed
calcaneus.
of
left leg. She is the sixth
On
of the
dimelia.
tarsal
patients
conditions
reported
in
to healthy
history
have reported
a foot
metatarsal
heads,
five
a cuboid,
age
contracted
They
three
These
her younger
sister are
maternal
and paternal,
reported
a case
and reduplica-
was also reduplication
and
the
the sound
podia.
three
and
deformed
and shortened
right leg and foot on which she
could not walk (Figs 1 and 2). She had only crawled
until
duplication
of the fibula with absence
of the tibia. In one
of their
cases,
the lateral
fibula
was longer
than
the
medial
one,
and,
paradoxically,
there
was also diplo-
with
metatarsal
These
are, therefore,
examples
of a
of a proximal
hypoplasia
or aplasia
girl
Pune,
each
toes and related
in four and totally
CASE
14-year-old
nine
of diplopodia,
toes,
remaining
fibula
and absence
in the amputated
Centre,
short.
Cases
in the
supernumerary
was hypoplastic
later.
There
were
six cases
extra
corresponding
with a distal
duplication.
hereditary
nor familial.
We report
a case
deviation.
(1978),
double
findings
according
with
whereas
two
tibia
of the tibia:
in
in the second,
upper
segment
the
proximal
are present
reported
is
lies in a varus
and Lloyd-Roberts
the diaphysis
and
There
three
extra
foot
a monstrous
tibia
and the
two fibulae
cuneiforms.
had two.
(1973)
were
The
or aplastic
were
carried
bones,
metatarsal
there
are three
degrees
of malformation
the first, the tibia is completely
absent;
only the proximal
epiphysis
and a short
are
present:
and,
in the
third,
both
and
and four
one which
in
and
a hypoplastic
There
was done and a prosthesis
fitted
in the leg and foot were duplicated.
Karchinov
of
This
from
polydactyly
additional
toes;
The formation
of an entire
The whole
doub)e
foot has
appearance
no kneejomt.
disarticulation
ofthe muscles
condition
should
where
there
are
bones
never
was
A through-knee
dissected.
Many
Diplopodia
is manifested
foot, the duplication
being
diplopodia
and there
was ill-developed
tibia and the patella
were absent.
The amputated
leg and foot were
was
slim
abnormalities
but
apart
foot.
a deformed
great
on
toe
either
1 001,
having
short
side
backwards
Pune-I,
foot
(rather
with
of it (Fig.
the
heel
AND
JOINT
nine
toes,
in length)
3).
The
pad
and
India.
lisdia.
R. Mysorekar.
Surgery
0301-620X182/2036-0206
$2.00
THE
JOURNAL
OF BONE
SURGERY
DIPLOPODIA
WITH
Fig. 1
Figures
sole
than
that
patient
upwards
and
before
of the
left.
limb
AND
AGENESIS
OF
207
TIBIA
the
treatment.
dorsum
of
the
foot
Movements
at the ankle joint
There
was flexion
contracture
the knee
with
limitation
of the right lower
limb
of the right
the
2-The
downwards.
restricted.
degrees
at
musculature
FIBULA
Fig. 2
1 and
pointing
pointing
markedly
DOUBLE
of
was
Measurements
flexion.
The
less developed
showed
by 26 centimetres
were
of 45
shortening
predominantly
below
knee.
A
radiograph
that
the
showed
developed,
were
two
of the right
lower
end
there
fibulae
being
almost
knee
and leg
of the
femur
(Fig.
was
no normal
knee
joint.
identical
in length
and
the upper
ends of which
of the femur
on its medial
projected
above
side. There
was
4)
ill-
There
shape,
the lower
end
no tibia and no
Fig.
patella.
The
patient
after
5
amputation.
Treatment
In view
of the
marked
shortening
of the
right
leg,
absence
of the right knee and the deformity
of the
foot a through-knee
disarticulation
was done
on
June,
1 980. Two weeks
later a temporary
prosthesis
fitted
After
to enable
two weeks
her to learn
of training
through-knee
end-bearing
5). The
patient
has now
extremely
happy
with
aspects
of the
Anatomical
to walk
with the
the
right
30th
was
for the first time.
pylon
a definitive
prosthesis
was provided
(Fig.
been
fully rehabilitated
and is
the
functional
and
cosmetic
prosthesis.
findings
It was
initially
vessels
intact,
aimed
to keep
but,
as
the
all the
dissection
nerves
and
blood
progressed
this
became
impossible.
Hence,
the muscles
and bones.
The
the findings
are restricted
toes are numbered
from
to
the
medial
being
axis
for
border
of
side,
reference
the foot.
VOL.
64-B.
the
has
No.
great
been
2,
1982
toe
considered
the
as the
fifth.
medial
The
-
Fig. 6
Figure
medial
muscles,
muscles.
Fig. 7
6-The
two parts
of the triceps
surae
muscle.
Note
that the
part
is larger.
Figure
7-The
two flexor
digitorum
longus
the
two
flexor
digitorum
accessorius
iind
the
lumbrical
Note
that the medial
flexor
digitorum/accessorius
muscle
is
larger
than
the lateral
one.
208
I. C.
The
two
and
flexor
digitorum
a lateral,
each
the
posterior
the
longus
muscles
arising
from the
surface
were
the ankle.
the lateral
respective
fibula.
in separate
strong
while
the
the extensor
supplied
toes.
The
expansion
of the
middle
into
five
medial
arose
the
two-thirds
tendons,
each
which
second
form
and
medial
the
for
of an expansion
On the medial
the
tibialis
two-thirds
passed
medial
ankle.
fibula.
The
entered
the foot
was
a thin
muscle
two
fibulae
were
which
bone
was
was
bellies
arose
belly
from
tendons
fourth
side
gave
in
three
from
the
to
toes.
of the
tendons
area
the
fourth
toe
to
the
roots
which
tarsi
to
arose
The
third
belly
the
great
the
from
middle
fibula.
It
half
of the
extending
the
base
between
toes.
The
the sixth
three
to the
part supplied
the
two other
flexor
of the
into
ninth
first
the
toes
and
ninth
base
of
respectively.
the
eighth
respective
flexor
digitorum
brevis
muscle.
ofthe
and
fourth
deep
first
The
tendon
of
navicular
medial
belly
lateral
calcanei.
abductor
and
and the
metatarsals.
muscle
to the
inserted
into
bases
of the third,
It was inserted
metatarsal.
aspect
ninth
the
toe
arising
lateral
side
of
The
of the
transverse
tendon
of the
fourth,
into the
head
eighth
and
base
of the
arose
oblique
from
the
and
was
head
inserted
into the third,
sixth, seventh
and eighth
toes. In
the lateral
half of the foot there
were
eight
interossei,
four dorsal
and four plantar.
The plantar
interossei
arose
from the sixth to the ninth
metatarsa)s
and were inserted
into
the
medial
side
of the
base
of the
respective
proximal
inserted
phalanges.
into the
one on
second
gave
toes.
aponeurosis
an
calcaneus
Of the dorsal
proximal
phalanx
interossei,
of the
two
seventh
were
toe,
whereas
the sixth and eighth
toes had one each.
On the
medial
side of the foot the dorsal
and plantar
interossei
were
almost
fused
at their
origins,
and were
inserted,
digitorum
the
cuboid
ninth
of the
ofthe
was
the
the base of the proximal
phalanx.
The oblique
head
of
the adductor
hallucis
arose from the plantar
aspect
of the
brevis
and medial
side of
supplied
the lateral
toe. The lateral
belly
the plantar
from
from
The
calcanei.
part, the
Fig. 8
and the intermediate
them.
On the sole of the foot
two
aspect
medial
the
and
fibres
were
inserted
of the first and
The
There
the
parts,
sixth
arose
toes.
toes
tertius.
muscle,
the extensor
second,
seventh
the two of the medial
toes.
There
were
and
phalanx
extensor
attached
the
to the base
of the foot
intermediate
by transverse
which
muscles
to the
8) arose from both
and a larger
lateral
to the third
and
sixth
the lateral
part
supplied
toes, while
and
third
metatarsals
proximal
presumably
upper
to that
the dorsal
between
first,
The
third
medial
the peroneus
sinus
eighth
second
(Fig.
part
calcaneus.
from
the
by a thick
each
joined
the
tendons
tendons
of
the. third
aspect
arose
from the lower
part of the
into the dorsal
aspect
of the base
In front
of the peroneus
brevis
into
in the midline.
On the dorsum
brevis
from
presumably
inserted
to the
of the
to be attached
joined
being
for
brevis
medial
It divided
medial
superficial
metatarsal.
The brevis
fibula
and was inserted
of the ninth
metatarsal.
two
slips
a separate
and was inserted
into the
On the lateral
side there
in a common
retinaculum
at
arose
passed
digitorum
a smaller
muscles.
of both
these
two
muscle
arose
surface
longus
Its tendon
into
flexor
It had
to the
lateral
was a muscle,
which
of
were
and
of the
there
divided
into the
toe and
fibula.
first
to the
under
a retinaculum
the first metatarsal.
two
peronei
enclosed
base
the
side
anterior,
had
anterior
and two for the fourth
toe. Between
muscles
there was a small unidentifiable
in the
P. MATHUR
membrane.
It passed
into five tendons,
one
eighth
and two for the
of the
one
the
flexor
digitorum
the larger.
They
of the
muscle,
from
of
to
B.
and were inserted
into
longus
tendon.
There
The
first
three
were
the
interosseous
fibulae
and divided
sixth,
seventh
and
retinaculum,
at
tendon
the first
fourth
toes respectively.
The fourth
was inserted
sixth toe, the fifth and the sixth into the seventh
the seventh
into the ninth
toe.
There
were two extensor
digitorum
longus
The lateral
arose
from the lower
three-quarters
fibulae
and
between
the
each
for the
two
retinacula
tendon
ninth toes. There
were two
muscles,
the medial
being
into
The
with the
supplied
lateral
arose from the respective
calcanei
the respective
flexor
digitorum
were
seven
lumbrical
muscles.
ninth
R. MYSOREKAR,
(Fig. 7), a medial
lower
two-thirds
of
partial
decussation
the medial
tendon
toes
sixth to the
accessorius
of the
enclosed
After
muscle,
fourth
inserted
V.
The triceps
surae
was in two parts,
the
the larger
(Fig. 6). Both had two heads
and
into the respective
calcanei.
There
were
muscles.
medial
being
were
inserted
muscles
NARANG,
had
It
either
side,
into the proximal
phalanges
to the fourth
toes.
The
flexor
hallucis
arose
from
was inserted
the
great
toe.
The bones.
been
were
conclusive,
removed
base of the fifth and sixth
into the base of the distal
Since
the
radiographs
of the
longus
metatarsals
phalanx
of the
foot
and
of the
had
at the end of the dissection
all soft
from the bones
revealing
that there
THE
JOURNAL
OF BONE
AND
JOINT
not
parts
were
SURGERY
DIPLOPODIA
WITH
DOUBLE
FIBULA
AND
fused
the
on
left.
calcanei.
AGENESIS
the
right
but
Similarly,
The
tarsal
generally
smaller
phalanges
and
209
OF TIBIA
there
was
bones
were
in
the
was
there
size.
rest
a joint
between
them
a joint
between
the
The
had
of normal
shape
fifth
had
three
toe
on
two
though
only
phalanges
two
each.
DISCUSSION
In the
present
be considered
in size and
case,
The
duplication
together
with
Fig. 9
The
tarsal
bones
after
the
have
been
removed.
soft
parts
metatarsal
bones
of the
diplopodia”
.
calcanei,
cuboids,
one
one
talus,
on
one
either
navicular
side,
between
the cuboids,
the most
the medial
cuboid
(Fig. 9). The
in the midline,
and
four
two
monsters
to amuse
been
presented
cuneiforms
medial
being
fused
talus and calcaneus
with
were
give
right
bones
enough
foot
No particular
It
monstrosity.
two
two
of the
of some
muscles
the
duplications
duplication
“
the
leg should
to be fibulae
as they were almost
shape:
the tibia is to be considered
challenge
the
stimulate
anatomists.
has
been
evidence
of
the
that
a partial
of the
nature
present
case
the
medical
regarding
use
foot
and
term
can be assigned
said
itself. The
to amuse
surgeons
of the leg and
of some
tarsal
to justify
cause
both
identical
absent.
the
to this
creates
has
therefore
public,
to
treatment
and
to
REFERENCES
iones
D, Barnes
i, Lloyd-Roberts
GC. Congenital
aplasia
and dysplasia
of the tibia with intact
fibula.
J Bone Joint
Karchinov
K. Congenital
diplopodia
with hypoplasia
or aplasia
of the tibia. J Bone
Joint
Surg
[Br) 1973:55-B:604Laurin
CA, Favreau
iC,
[Am)
1964:46-A:137-42.
Mysorekar
VR,
VOL.
No.
64-B,
Lohokare
2.
1982
Labelle
5K.
P. Bilateral
A case
absence
of eight-toed
of the radius
foot.’Br
and
J Radiol
tibia
with
l970:NS
bilateral
43:740-2.
reduplication
of the ulna
Surg
and
[Br) 1978:60-B:3l
1 I.
fibula.
J Bone
-9.
Joint
Surg