Fracture of the os calcis

Fracture of the os calcis

FRACTURE OF THE OS CALCIS PAUL B. MAGNUSON, M.D. AND FRANK STINCHPIELD, M.D. Instructor in Surgery, Northwestern University SchooI of Medicine ...

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FRACTURE OF THE OS CALCIS PAUL

B. MAGNUSON,

M.D.

AND

FRANK

STINCHPIELD,

M.D.

Instructor in Surgery, Northwestern University SchooI of Medicine

Professor of Surgery, Northwestern University School of Medicine

CHICAGO, ILLINOIS

T

subject of fracture of the OS caIcis has been of persona1 interest for a good many years. Whether it be a fresh fracture or an old fracture with pain and disabihty, the seIection of the method of individua1 treatment is important. The mechanics of production of the fracture are practicaIIy aIways the same: a faII from a height, the body weight striking on the hee1. If one Iooks at the anatomy of the foot, one sees that the OS caIcis normaIIy Iies with about two-thirds of its entire bulk IateraI to the mid weight-bearing Iine of the foot, and the other one-third media1 to this Iine. The impact of the weight of the body against the hee1 drives the posterior two-thirds of the OS caIcis upward and outward and compresses it. The bone is of canceIIous nature and practicaIIy never fractures twice in the same lines. The Iines of fracture are irreguIar and are not in pIanes easiIy shown by an anteroposterior and IateraI view in the x-ray. The impaction shortens the hee1 from front to back and widens it from side to side, and carries it upward and outward. In view of the fact that the OS caIcis is shortened and the posterior two-thirds are driven upward toward the fibuIa, the foot is thrown into a pronated position, the IongitudinaI arch is Iowered in proportion to the amount of upward dispIacement of the posterior fragments; the peronea1 tendons are dispIaced outward or pinched between the IateraI surface of the OS caIcis and the fibuIa. Further, whenever a fracture of the OS caIcis occurs there is immediate and rapid swelling around the posterior surface of the foot and ankIe, which extends forward and upward, foIIowed quickIy by bIeb formation if not checked. HE

There have been many methods devised to reduce this fracture and maintain it in reduction. This, on the face of it, impIies that none of these methods is easy to apply with the assurance of a satisfactory resuIt. What hoIds true with other conditions in medicine appIies here-no two cases are exactIy aIike. Each must be analyzed and the necessities of each case must be considered. Methods mean nothing unless they are appIied inteIIigentIy and are adapted to the case in hand. Numerous diffrcuIties are encountered in attempting reduction. Fracture of the OS caIcis is aIways an impacted fracture; further, it is impacted so firmIy that great force properIy appIied is necessary to disimpaction disimpact it, and without nothing can be gained by any treatment. Tongs, maIIets, wires or pIaster casings are useless unIess they tend to improve the position of the fragments and maintain them in the improved position. From personal experience it seems that the first step in treatment is to prevent sweIIing and rapid bIeb formation which generaIIy occurs as an immediate result of this fracture. The most satisfactory method in our hands for meeting this requirement is a piIIow spIint as advocated by Gurd. When properly appIied, this wiI1 absoIuteIy prevent the occurrence of bIeb formation and wiI1 reduce the swelling to a point where, within the short space of forty-eight hours, the treatment necessary for reduction of the fracture can be appIied. Rather than permit sweIIing to occur, it is preferabIe to postpone the x-ray and put on a piIIow spIint or massive compression dressing promptIy. The fragments do not change position; it is the sweIIing and bIeb formation onIy that prevent reduction within a coupIe of days

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after occurrence of the fracture. Should there be bleb formation, which cannot be cIeared up in Iess than ten days or two

FIG. I. Lateral-obIique

FIG. 2. “SaIient

angIe” as described by Bijhler.

Visualization by x-ray should aIways incIude stereoIatera1, IateraI-obIique and anteroposterior views. A satisfactory anteroposterior fiIm can be obtained by pIacing the plate against the soIe of the foot, the patient in prone position, bringing the tube cIose to the back of the knee and projecting the ray downward paraIIe1 to the

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Iong axis of the tibia. This wiI1 give a view of the posterior two-thirds or three-fourths of the OS caIcis with the maIIeoIi. The

x-ray to show triangular

weeks, treatment must be postponed unti1 fixation can be appIied. Therefore, if swehing is permitted to occur, reduction of the fracture must be deferred unti1 such time as the skin is in condition to toIerate the apphcation of some fixation.

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fracture of anterior OS calcis.

IateraI-oblique (Fig. I) is taken to show a smaI1 trianguIar piece which extends into the joint in the upper IateraI surface. No other view wiII show this smaI1 fragment which, if it is present, forms a troublesome comphcation and wiII produce a permanent painfu1 posterior tarsus. The perpendicmar view wiI1 give information regarding the widening of the OS caIcis and the amount of dispIacement of the posterior twothirds. The IateraI stereo will show the Iines of fracture into the astragaIocaIcanea1 joint, as we11 as the amount of change in the saIient angIe, as described by BohIer. (Fig. 2.) BiihIer says, that “if two Iines are drawn aIong the upper aspect of the caIcaneus, one from the highest point to the anterior angle, and the other from the highest point to the upper part of the tuberosity, these two Iines wil1 normaIIy make an angIe of 140 to 160 degrees with each other, the compIementary angle being 20 to 40 degrees. This angle, which is easiIy measured by the eye, is known as the tuberosity joint angIe, or saIient angIe. In a fracture of the OS caIcis, the angIe becomes smaIIer,

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disappears, or is sometimes reversed. It is an important determination in recognition of fracture of the OS calcis.” It must be remembered in all these views that the planes of fracture are not we11 defined, as in cortical bone, and the exits of Iines of fracture on the various surfaces must be carefuIIy studied to determine the number of fragments and the amount of compression, as we11 as the amount of displacement. The same thing happens here that happens in CoIIes’ fracture or any other compression of canceIIous bone. The vioIence which causes the fracture and impacts the fragments actuaIIy disintegrates the bone ceIIs, causing permanent Ioss of tota length, so that no amount of manipulation wiI1 compIeteIy restore the bone to its norma shape. Therefore, we seek to accomplish certain things in reduction, nameIy : (I) To break up the impaction, (2) to enabIe remoulding of the fragments downward and inward away from the externa1 maIIeoIus, and to restore them to their norma position in relation to the mid weight-bearing line of the foot; (3) to increase the height of the arch and to reestablish the mechanics of the foot, enabIing it to bear weight again without pinching the peronea1 tendons, and to avoid throwing undue strain on any of the mechanica structures that support the weight of the body as it appIies to the foot; (4) to restore the pIantar fasciae to norma Iength. Another compIicating factor in this fracture is entrance of the fracture Iines into the astragaIocaIcanea1 joint. The fact that this so often occurs would seem to be one of the governing factors in the choice of method of treatment. An irregular, rough astragaIocaIcanea1 joint with adhesions wiI1 probably produce pain regardIess of the position of the OS calcis. There is no doubt but that adhesions in this joint occur aImost inevitabIy in fracture of this bone. In addition, there is thickening and induration which resuIts in fibrosis of the interna

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and externa1 IateraI Iigamentous supports, and these three things taken in combination aIways produce some Iimitation of Iateral motion. Constant weight bearing subsequent to fracture, on a joint which is rough and irregular, wiII produce traumatic arthritis regardIess of other conditions. Treatment shouId be planned with reference to the amount of damage that has occurred to the joint at the time of fracture. How best to meet the requirements of each case is a matter of individua1 opinion. There are certain fundamenta1 principIes invoIved. The technique necessary to care for this particuIar fracture wiI1 have to be devised. It may be that none of the we11 pubIicized methods wiI1 meet the r.equirements and a combination of severa wiI1 be necessary. Whether the impaction is broken up by striking the outer side of the hee1 with a maIIet; whether it can be manuaIIy accompIished; or whether a carpenter’s clamp is required, wiI1 be determined by the result of the operator’s experience in using one or more of these methods. The fact remains that the impaction must be broken up compIeteIy in order to mouId the OScaIcis back into shape and into position. How best to hold it in position must also be determined at the time of manipulation. Too much pressure cannot be applied to hoId the fragments, because the skin of the hee1 and soIe wiII not toIerate undue pressure over even a limited period. A sIough may be caused by too much force or too much pressure over too Iong a period, and a sIough on the hee1 is a major disability in itseIf. METHODS

In rgI 7 one of the authors1 advocated cutting the tendo AchiIIes to reIieve the fragments of the dispIacing muscIe action of the gastrocnemius and soleus. This was very effective so far as maintenance of position of the fragments was concerned. It was discontinued when it was found that the caIf muscIes were permanentIy weakened as a resuIt of the procedure.

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They never returned to their fuII strength and consequentIy there was a disabiIity in the Ieg, aIthough the resuIts so far as the OS caIcis was concerned were better than those obtained by any other method. Pins and caIipers of various kinds have been advised for the maintenance of fragments in position. It is true that there is usuahy one major posterior superior fragment, but this may be onIy one of a dozen fragments which, after the impaction is hnaIIy broken up, do not offer the possibiIity of being mouIded into the norma contour by traction on one fragment only. If the OS caIcis were broken through the body in a cIean transverse Iine, a pin or wire through the OS caIcis with weight appIied sufficient to baIance the puI1 of the gastrocnemius and soIeus, wouId answer the purpose, but fractures of this type are seIdom seen. A cornminuted fracture cannot be reduced and a11 the fragments maintained in reduction by putting traction on one fragment even though it is of Iarger size than the others. The treatment, then, resoIves itself down to disimpaction of a11 fragments with proper mouIding of these fragments into the norma angIe and the normal position of the OS caIcis. There have been various methods advanced, all of which have strong points in their favor, and none of which wiI1 answer the requirements in every case. It is not possibIe in a paper such as this to offer a review of al1 the methods offered during recent years for treatment of these cases. Most of them have been devised at a time when it was necessary to meet the requirements of an individual fracture, and may not be appIicabIe to the case at hand. The surgeon must therefore determine the requirements of his particuIar case before deciding what method or combination of methods will best suit his purpose. In reviewing the various methods and from persona1 observation, the foIIowing appear to be the most IogicaI procedures; they are based on variations of the same sound principIes :

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Hermann’s Metbod. This author’s2 desire to reduce this fracture and hold it in reduction was prompted by the observation that in a Iarge number of cases, IO per cent developed sepsis where Kirschner wire or a Steinmann pin were used. He concIuded that traction through a traumatized area was surgicalIy unsafe, with which view we fuIIy agree. He therefore first pIaces the Iower Ieg, ankIe and foot in a compression dressing, preferabIy a piIIow splint, to prevent sweIIing and bIeb formation. When sweIIing has subsided suffrcientIy, the patient is anesthetized and turned on the side opposite the injury. A sandbag is pIaced under the inner surface of the injured hee1: a tightIy roIIed linen towe is pIaced over the lateral surface in an obIique position with its Iower end just beIow the tip of the externa1 maIIeoIus. Solid heavy bIows from a moderateIy heavy rubber or feIt hammer are struck on the towe beIow and behind the externa1 maIIeoIus unti1 the impaction is compIeteIy broken up and until a depression can be feIt beneath the tip of the external maIIeoIus to about the depth of the surgeon’s thumb. The hee1 is then grasped between the operator’s hands and mouIded downward and inward, motion of the subastragaIar joint being tested at the same time. FoIIowing this, ice-tongs are pIaced in the Iarge posterior superior fragment. The upper portion of a sawedoff crutch is pIaced just anterior to the border of the OS caIcis on the soIe of the foot: the opposite end of this crutch is pIaced against the operator’s chest, and the heel is puIIed downward with the ice-tongs and further moulded. Hermann advises traction on the ice-tongs downward and outward, sIowIy changing the direction to inward. The ice-tongs are removed and further mouIding is accomplished by Iateral compression with a redresseur. X-rays are then made to be sure that a satisfactory reduction has been obtained. SmaII rolls of felt, measuring 4 by 1>/4 inches are pIaced at a sIight obIique angle beneath each maIIeoIus. These pads, when

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in pIace, serve as pressure pads to prevent excessive bone formation. A pIaster boot is then apphed, extending from the knee to the toes. The foot is heId in sIight inversion and extreme plantar Aexion during the time the pIaster is hardening. Hermann feeIs that the after-care of these cases is the most important step of the entire procedure. The pIaster and submaIIeoIar pads are replaced every two weeks, care being taken to keep the foot at a right angIe when the second pIaster is applied. Constant snug pressure must be maintained beIow the maIIeoIi. FoIIowing remova of the plaster at the end of ten or tweIve weeks, a special ambuIatory OS caIcis brace is appIied. DaiIy massage and active foot and ankle motion are started; supination, pIank waIking, hot soaks and radiant heat are instituted. Weight-bearing is permitted within two weeks after removal of the last piaster, the shoe being fitted with an inner soIe and $i6 inch Iift on the inner margin of the Thomas heel. The splint is graduaIIy discarded about eighteen weeks after the initia1 reduction. Hermann reports 132 cases treated by this method, in 73 per cent of which the resuIts were good, in 14 per cent fair and in 13 per cent poor. He beIieves the good results are due chiefly to the after-treatment which tends to maintain continued pressure beneath the maIIeoIi and prevents piIing up of bone. The rationale of this treatment seems exceIIent. We have visited Hermann’s cIinic and have seen some of his cases, and were impressed by the thoughtfuIness and care shown in the reduction and aftertreatment. The principIes upon which the treatment is based show an understanding of the probIems invoIved. Conn’s Method. Conn3 reported a series of cases in which he used four different methods, but he does not say upon what points of variation in the fractures he based his choice of method: (I) subastragalar arthrodesis, with or without regrooving for the peronea1 tendons; (2) combined forcibIe latera compression of

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the OS caIcis with skeIeta1 traction; (3) a two-stage operation of IateraI compression and skeIeta1 traction for five weeks, foIIowed by a combined subastragaIar, astragaIoscaphoid, and caIcaneocuboid fusion; (4) on oId cases in which a painfu1 subastragalar motion was present, a tripIe arthrodesis. He feeIs that the resuIts obtained were by far the best when the third method was used. Briefly, his technique is as foIIows : A heavy wood cIevis is appIied just beIow both maIIeoIi which, when tightened, acts as a disimpactor, inasmuch as it breaks up the bone so that it may be mouIded easily. FoIIowing this step, stee1 fixation is used in the form of a Steinmann pin through the Iower tibia and the tuberosity of the OS caIcis. Reduction is maintained by traction in opposite directions on these pins by a stee1 arc running posteriorIy from one pin to the other and incorporated in the plaster boot. This position is continued for five weeks. The second stage, at the end of five weeks, consists of fusion of the subastragaIar, astragaIoscaphoid and caIcaneocuboid joints. AI1 excess bone under the IateraI maIIeoIus is removed (Scoop operation). Three weeks Iater the pIaster is removed and the position of the foot is observed. If it is not satisfactory or if there has been any sIipping, the position can be corrected at this time. New pIaster is then applied. Eight weeks after the fusion operation, weight-bearing is started sIowIy and cautiousIy, care being taken to prevent any undue strain on the Iongitudina1 arch. Conn credits his success to the fact that the depressed sustentacuIum taIi, which is so often overIooked, is recognized and corrected. In Conn’s hands, this method gave better than average resuIts, but it certainIy constitutes a major surgica1 procedure in two stages. Judging from our persona1 experience with these fractures, this wouId not be justified in the average case. We beIieve that thoughtfu1 treatment aIong Iess radica1 lines wiI1 produce as good

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resuIts, with Iess hazard of serious consequences as a resuIt of infection around the Steinmann pin or infection at the time of the second stage operation. Go$‘s Method. This method4 is designed to aIIow the patient to be ambuIatory within forty-eight hours after reduction is effected. Goff uses a carpenter’s cIamp, as described by Yergason, for both anteroposterior and IateraI compression or disimpaction of the fracture. The cIamp is used because of the greater force obtainabIe, which permits puIIing the hee1 into position at once. Goff feels that this obviates the need for continued traction. PIaster is applied from toes to mid-thigh, with the knee flexed 20 degrees. The BijhIer walking iron is incorporated immediateIy and the patient is permitted to waIk within forty-eight hours, the weight being borne on the iron. At the end of the second week the pIaster is cut beIow the knee and after ten weeks it is removed; fuI1 weight-bearing is permitted at the end of eIeven weeks. This procedure takes into consideration the remouIding and reposition of the fractured fragments of the OS caIcis. A great dea1 of force is used with the cIamp to mouId the fragments, or practicaIIy pinch them into shape. The Aexion of the knee, the cast extending above onto the thigh, indicate that the author wishes to reIease the puI1 of the tendo AchilIes, which seems important. However, even with a waIking iron, if there is a tight fit of the pIaster around the OS caIcis, as there must be to hoId the fragments in position, the bearing of weight on the waIking iron wiI1 force the cast upward as the weight of the body comes down against it; consequentIy there must be pressure on the inferior surface of the OS caIcis and a tendency to force it up into its oId position. The advisabiIity of aIIowing a patient with a fractured OS caIcis to be ambuIatory within forty-eight hours is questionabIe. True, it saves confinement and time in the hospita1, and the companies who frequentIy have to pay for such injuries

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appreciate this reduction in hospital days, but from a surgical standpoint the welfare of the patient and securing a usefu1, painIess weight-bearing foot, is much more important than the saving of a few hospita1 days. Our feeIing has been that this procedure was rather radica1 as a primary method and shouId be resorted to onIy when more conservative methods have faiIed. Biihler’s Method. ProbabIy more has been written on the BijhIer methdds of reduction and treatment of the fractured OS caIcis than on any other procedure. There have been frequent modifications of his origina technique, by other surgeons and by Professor BijhIer himseIf. His present treatment is approximateIy as foIIows : In aImost every case the injured Ieg is eIevated on a Braun frame without traction. Light massage is instituted to decrease the amount of sweIIing. UsuaIIy, no skeIeta1 reduction is attempted for eight or nine days, at which time, with the patient under spina anesthesia, a Kirschner wire is inserted through the OScaIcis and an immediate reduction on a BijhIer frame is performed. The Iine of puI1 for reduction depends on the type of fracture, the traction usuaIIy being at a 45 degree angIe to the tibia, downward. From 55 to 60 pounds of traction is necessary to accomA BijhIer redresseur is pIish reduction. used for IateraI compression. He has discontinued the use of the Kirschner wire through the tibia for countertraction because of the danger of infection in the tibia1 region and about the ankIe joint, which he states he has observed rather frequentIy. He depends on countertraction from the flexed knee on the BijhIer frame at the time of the initia1 reduction. When reduction is obtained, a nonpadded skin-tight pIaster is appIied, carefuIIy mouIded about the foot and ankIe. The Ieg is again put on a Braun frame, and traction of 15 pounds is appiied on the Kirschner wire. This remains constant for six weeks, at which time the wire

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is removed and a new pIaster is appIied, into which is incorporated a waIking iron. This is removed six weeks Iater. At the end of fourteen to sixteen weeks after the initia1 reduction, the pIaster and waIking iron are discarded and fuI1 weight-bearing is aIlowed. The patient is fitted with a shoe containing an inner soIe to maintain the newIy formed IongitudinaI arch. BiihIer’s method has proved very satisfactory in the hands of a number of surgeons. One of the authors has observed BiihIer’s work and resuIts within the Iast year. BiihIer himseIf, however, gives no such rosy and ideal picture of the resuIts of this method as seems to be prevaIent This is probabIy due in this country. to the fact that the BijhIer apparatus and method have been publicized to a Iarge extent through the saIe of the equipment which he has designed and used. The occurrence of traumatic arthritis is frequent. BiihIer cautions against the overuse of the redresseur because of the possibility of sIough. He aIso cautions against too earIy weight-bearing. He had not been using a compression dressing to prevent bIeb formation, but eIevated the foot for ten days before starting treatment. Extension was maintained and the patient was kept in bed for six weeks foIlowing reduction, after which a skin-tight pIaster was applied. Note is made here that neither weight-bearing nor dependent position was aIIowed unti1 a11 possibiiity of displacement of the fragments and undue sweIIing had been eIiminated by time. Wilson’s Method. WiIson,” in 1927, concIuded that it was aImost impossible to get anatomic reduction in fracture of the OS caIcis, and advised immediate subastragaIar arthrodesis. This method he foIIowed for some time. He exhibited very satisfactory resuIts so far as painIessness was concerned, but the deformity produced by impaction and displacement of the fragments was not changed, except insofar as the OS caIcis was moved somewhat inward at the time of operation, and the heeI inverted somewhat more than is

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usuaIIy the case immediateIy foIIowing fracture. W&on’s resuIts were probably due to the fact that at the time of operation he was abIe to restore, more or Iess, the weight-bearing position of the OS calcis, with its two-thirds IateraI to the mid weight-bearing Iine and one-third media1 thereto; aIso the whoIe bone was moved mediaIIy at the time of operation. This is a vaIuabIe operation and is necessary in probabIy 30 to 35 per cent of cases even after proper reduction, but in our opinion it shouId be postponed unti1 the fracture is reduced and healed in as near anatomic position as it is possibIe to attain. Then, if the patient has a painfu1 astragWiIson’s procedure aIocaIcanea1 joint, shouId be foIIowed. In these cases, the operation properIy performed gives a highIy satisfactory result after ankyIosis of the joint occurs. In 1923, one of the authors’ advocated an operation for the reIief of disability in oId fractures of the OS caIcis, which attempted to do what Wilson Iater effected with an arthrodesis. In this operation the mass of callus which Iies behind and beneath the externa1 maIIeoIus, which is an outgrowth of the widening and fracture of the OS caIcis, was removed with a gouge, and the groove Ieft much deeper than normaI. This part of the operation has been done frequentIy, and is advocated by Cotton and others. This, however, was considered by us onIy the first step The second step has in the operation. apparentIy never been given consideration either in the Iiterature or in discussion, and the second step is just as important as the first, if not more so. After the mass of bone had been removed from behind and beneath the externa1 maIIeoIus and the Iateral supports of the ankIe severed in getting to this excess caIIus, a Thomas wrench was applied with the proxima1 arm Iying aIong the outer margin of the foot over the OS calcis, extending forward over the fifth metatarsa1, the distaI arm lying against the media1 side of the astragaIus just below

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the interna malIeolus. With strong, smooth, steady pressure the foot was inverted, and with it the OS caIcis was carried mediahy. Frequently in this procedure a ripping can be feIt and heard as the adhesions between the OS caIcis and the astragaIus are broken up. When the hee1 can be moved inward and maintained in that position by pressure on the IateraI side of the hee1, the wound is cIosed and the foot fixed with the heel in inversion. The height of the arch is increased by firm eversion of the part of the foot anterior to the astragaIus. It was found that a skin-tight pIaster, appIied to the Iower Ieg and hee1 and held hrmIy unti1 it was hard, was the easiest method of maintaining the hee1 in its position. The anterior part of the cast, with eversion of the front of the foot, was appIied after the posterior half had hardened. In this way the height of the arch was increased, the OS calcis was moved over to the midIine, and pinching of the peronea1 tendons was reheved. The resuIts of this treatment have proved highIy satisfactory. The so-calIed regrooving operation is incompIete. The inversion of the hee1 shouId be performed at the same time. SUMMARY

There has been a voIuminous Iiterature on fracture of the OS caIcis in the Iast ten years. The resuIts of treatment of this injury have improved, but the results wiII never be perfect in the hands of anyone,

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or as a resuIt of the use of any one method. It is a fracture in which a certain amount of bone has been destroyed. It is comminuted in canceIIous bone, and the major fragment is attached to a tendon controIIed by two of the strongest muscIes of the body. The bone must bear weight and be subject to the trauma of weight-bearing. To restore painless function impIies perfect mechanica restoration of bone, which frequentIy is impossibIe; it aIso impIies a freedom of motion between the OScaIcis and the astragaIus which is practicaIly aIways Iimited, regardIess of the methods used in reduction and maintenance of reduction. Therefore, idea1 resuIts are aImost impossibIe to attain. The future wiI1 present better resuIts, however, if carefu1 anaIysis of each case is made, and if the choice of treatment or combination of treatment is suited to and suitabIe for the individua1 case. REFERENCES I. MAGNUSON, P. B. Mechanics of fractures of the OS cakis. J. A. M. A., 68: 530-532 (Sept. 17) 1917. 2. HERMAN. 0. J. Treatment of fractured OS cakis. J. Bok &+Joint Surg., 35: 709-718 (JuIy) 1937. 3. CONN, HAROLD R. Treatment of fractured OS calcis. J. Bone CYJoint &up., 33: 392-405, 1934. 4. GOFF, C. W. CIosed reduction of fractures of OS caIcis. New England J. Med., 216: 293-298 (Feb. 18) 1937. 5. BATTLER,LORENZ. Fractures of the OScaIcis. J. Bone fl Joint .%rg., 29: 75-89 (June) 1930. 6. WILSON, P. D. Treatment of fractures of OS calcis bv arthrodesis of SubastraeaIar ioint. J. A. M. A., 89: 1676-1683 (May 18) rg27. ’ P. B. An operation for relief of disability 7. MAGNUSON, in old fractures of OS cakis. J. A. M. A., 80: 131 I-1513, 1923.