Over the past 25 years 110 children with 151 "flat-top" tali have been patients at the Shriners Hospital in Winnipeg. Seventy-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 iatrogenic 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.
Keim HA, Ritchie GW. "Nutcracker" Treatment of Clubfoot. JAMA. 1964;189(8):613–615. doi:10.1001/jama.1964.03070080019004
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