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Trauma to the Foot and Ankle
TRAUMA TO THE FOOT AND ANKLE
J.
HAMILTON ALLAN,
M.D.;:'
SPRAINS OF THE FOOT AND ANKLE
THE most common injury to the foot or ankle is a sprain of the lateral ligaments. It is important to differentiate between minimal damage to a ligament and a complete ligamentous rup~ure, for if the latter injury is not recognized and treated adequately healing does not occur and a painful relaxed ankle joint results. The lateral ligaments are composed of (1) the posterior talofibular, (2) the anterior talofibular, and (3) the calcaneofibular ligaments. Moderate swelling, and slight tenderness over the talofibular and calcaneofibular ligaments indicate a simple sprain which may be ideally treated by rest in bed, elevation of extremity, ice packs, early active mobilization, and weight-bearing with the aid of a Gibney boot strapping. Considerable pain, swelling and acute tenderness distal and anterior to the tip of the lateral malleolus aggravated by adducting the foot suggest a ligamentous rupture. The detection of rotation of the talus in the ankle mortis, as the foot is adducted, is additional evidence of a rupture. A radiographic study is made to determine the integrity of the ankle mortis. In a normal anteroposterior roentgenogram of the ankle joint there cannot be a translucent zone between botn talus and tibia and the talus and fibula. If such a zone is visible it indicates damage to the tibiofibular ligament with widening of the ankle mortis. If an anteroposterior roentgenogram of the ankle made with the foot passively adducted shows a luxation of the talus occurring in the ankle mortis (Fig. 454) the lateral ligament is ruptured. This study can be satisfactorily done with the area of injury infiltrated with 1 per cent procaine. If these studies indicate a complete rupture of the lateral ligaments, the hematoma formation is aspirated. Ice bags are applied for twentyfour hours. Hot compresses and the whirlpool bath are then used to reduce the swelling. When this has been relieved, a nonpadded plaster walking cast is applied and maintained for four to six weeks. The removal of the cast is followed by the application of an Unna paste boot or a Gibney boot strapping for ten days. Sprains may occur elsewhere in the foot. Metatarsal sprains are common. There is swelling of the forefoot, acute tenderness under the matatarsal heads, and extreme discomfort upon flexion at the metatarsophalangeal joints. The reCUlrence of this type of sprain is often associated with contraction of the calcaneal tendon and calf " Associate in Orthopedic Surgery, Graduate School of Medicine, University of Pennsylvania; Chief, Orthopedic Services, Germantown and Chestnut Hill Hospitals, Philadelphia.
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muscle. It responds satisfactorily to the application of a felt pad just proximal to the metatarsal heads and a strong adhesive support about the forefoot. When the acute' symptoms subside, a sponge rubber metatarsal support is inserted in the shoe and calf-stretching exercises are begun.
Fig. 454.-Rupture of external ligaments of ankle demonstrated by the marked rotation of the talus in the ankle joint mortis upon inversion of the foot.
FRACTURES AND DISLOCATIONS OF THE ASTRAGALUS
The astragalus (talus) has seven articulating surfaces and articulates with foui bones. It is the only bone in the body that has no muscular attachments. Its surface is largely covered by a nonvascular articular cartilage which responds poorly to trauma. The articular surfices are weight-bearing in function and are involved in all motions of the foot and ankle. The vascular supply of the astragalus is derived from branches of the anterior tibial artery which enter the superior astragalonavicular ligament and supply the superomedial aspect of the neck of the astragalus. The blood supply to the body of the talus is impaired if a fracture ,occurs in the neck proximal to the nutrient artery. Similarly, if the fracture occurs distal to the entrance of the nutrient artery, aseptic necrosis is a possibility. Because of its protected position between the malleoli an injury to the astragalus is rather rare, comprising approximately one fourth of the injuries to the tarsal bones. However, when a fracture occurs the disability may be considerable, because it results not only from the fracture itself but from the serious complications which accompany
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this injury. (1) Aseptic necrosis occurs very frequently because of the inadequate blood supply to the talus. (2) Traumatic arthritis, particularly of the tibiotalar joint, is rather constant because infraction of the cartilaginous joint surfaces is produced as a result of the impacting nature of the force causing the injury, and these cartilaginous surfaces do not heal satisfactorily. (3) Infection of the talus causes marked damage and is a common complication for the reason that so many of these injuries are compound fractures. Fractures of the astragalus are divided into three groups: ( 1) posterior process, (2) the neck, (3) the body. Fracture of the Posterior Process.-The posterior trigonal process is situated lateral to the groove of the flexor hallucis longus tendon and serves as an attachment for the fasciculus of the lateral ligament of the ankle joint. When the foot becomes plantar flexed, the posterior aspect of the talus rises upwards and approaches the lower margin of the posterior surface of the tibia. Impingement of the tibial margin against the posterior process during the action of acute plantar flexion of the foot causes the fracture. Diagnosis is made on the basis of an acute plantar flexion force, localized tenderness, pain with plantar flexion of the foot and on acute flexion of the great toe. The fracture is not a serious one, being outside the joint; however, it is of considerable medicolegal importance because of the necessity of distinguishing between a fracture and the os trigonum. The latter is a developmen,tal variation found in 10 per cent of normal individuals. Roentgen study of a fracture of the posterior process reveals soft tissue s~elling and a sharp irregular fracture surface as contrasted to the smooth regular outline of the os trigonum. The fracture heals satisfactorily with a six week period of fixation in plaster with the foot in neutral position. Fracture of the Neck.-Fracture of the neck of the astragalus is a dorsiflexion injury. It occurs as the neck of the talus is impacted against the anterior margin of the tibia, which is forced downward into the talus causing a vertical fracture. It is unusual to see a vertical fractute of the neck without displacement. So often is it associated with a posterior displacement of the posterior half of the subtalar joint that a fracture of the neck of the talus calls for a careful search for the posterior displacement. If there is no posterior displacement the treatment is immobilization in a cast for eight weeks. If there is the slightest suggestion of posterior displacement of the posterior half of the talus, the foot must be immobilized in plantar flexion and eversion, because only in this position is the alignment of the head and body of the talus to the calcis satisfactory. This position is maintained for eight weeks, then followed by a cast with the foot less dorsiflexed. Three weeks later the foot is brought to the neutral position and plaster immobilization is continued for four weeks.
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HAMILTON ALLAN
Fracture of the Neck of the Talus with Posterior Displacement of the Body.-This is an extreme dorsiflexion injury. Not often seen in civilian life, it proved to be a rather anticipated injury in aircraft accidents during the war. During a crash the rudder pedal forces the foot of the pilot into into acute dorsiflexion, fracturing the neck of the talus with the line of injury extending to the ligaments of the posterior part of the subastragalar joint causing a posterior displacement of the body of the talus. As the body of the talus is displaced, all soft tissue attachments are torn. The bone is thus deprived of its blood supply and avascular necrosis should be anticipated. This type of injury is extremely difficult to reduce. It is imperative to attempt an immediate closed reduction, for the extreme displacement of the body of the talus causes severe pressure on the under surface of the skin, and there is danger of compounding from within. The foot is manipulated into full dorsiflexion, the heel pulled forward, then everted to unlock the sustenaculum tali, and finally, while pressure is maintained on the posterior part of the body of the talus to prevent redisplacement, the foot is brought into plantar flexion. If this manipulation is not successful, open reduction is indicated immediately. A lateral incision along the ankle at the level of the subtalar joint is brought obliquely forward toward the talonavicular joint. The subastragalar joint is exposed, the sustentaculum tali and talus are unlocked and the talus pushed forward into position. The fragments are replaced into position and fixation is secured by directing a Kirschner wire across the fracture line from the head posteriorly into the neck and body and then cut off flush with the neck. Fractures of the Body.-Fractures of the body of the talus are usually comminuted and are accompanied by dislocation of the fragments into the soft parts in front of and behind the ankle. The posterior segment of the body may lodge beside the calcaneal tendon and the anterior segment may be rotated and thrown anteriorly. These fractures cannot be reduced by a closed manipulation and an open reduction should be done as early as the damaged soft parts are in good enough condition for surgery. Here again, after the fragments are replaced into position, fixation is secured by insertion of Kirschner wire or vitallium screw. The incisions are closed without drainage and the extremity is immobilized in a plaster cast for sixteen weeks. In all cases x-rays should be studied carefully for aseptic necrosis, and if it is present, full weight-bearing should be delayed until the bone has a normal appearance. In comminuted fractures of the astragalus, astragalectomy is often done. It should be emphasized that this procedure is attended by serious disability. While it has been successful in a few cases, the majority of results have been disappointing. The technic of astragalectomy was devised for paralytic calcaneovalgus foot where there is usually a muscle weakness in the plantar flexors and adductors of the
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foot. In the traumatic lesions of the talus there is no muscle imbalance. It is difficult to balance the adult foot between the malleoli, and the foot usually goes into varus thus producing a crippling deformity. The best functional results occur from those astragalectomies which will be followed by fusion of the tibia and os calcis. This fusion is to be expected as a sequel to infection, and astragalectomy is performed without hesitation when an infected talus has to be removed before healing will occur. In this event fibrosis or ankylosis occurs limiting the motion between ankle mortis and articulating surface of the os calcis, and if the foot can be maintained in a satisfactory position during the period of fibrosis, a satisfactory foot will result. Occasionally astragalectomy has to be performed where comminution of the talus is extreme. In such instances the foot should be maintained well forward where the anterior margin of the tibia is in a vertical plane with the calcaneocuboid jOint. A calcaneotibial arthrodesis should be done and the foot placed in equinus of 5 degrees in males, and 10 to 15 degrees in females. With the exceptions of the two indications cited above-infection and extreme comminution of the talus-other surgical procedures are preferable to astragalectomy. Where the astragalus has been comminuted, the blood supply seriously disturbed, and the many fracture lines cause a disruption of the articular surfaces, a subastragalar arthrodesis, an ankle fusion or a pantalar arthrodesis may be done. It does not seem reasonable to do these procedures early. The patient should be allowed a test of function for about a year in order to determine which joints should be fused. A surgical arthrodesis of the painful articulations yields a painless and stable weight-bearing foot. Dislocations of the Talus.-Dislocations of the talus are classified by the direction of the displacement. Three distinct groups are evident: (1) supination, (2) dorsiflexion, (3) adduction and abduction. In each group the type of displacement depends upon the force involved. Inversion of the foot causes rupture of the lateral ligament, disloca-. tion of the ankle joint, and if strain continues the interosseous ligament of the subtaloid ruptures allowing the talus to stay in the tibiofibular mortis but the other tarsal bones dislocate inward. This is the subastragaloid dislo~ation. The talus remains in an equinus position. In reducing this dislocation the foot is plantar flexed, then everted and abducted. The ankle is immobilized for six weeks in a walking plaster with the foot in right angled dorsiflexion and neutral lateral position. It must be borne in mind that by the very.nature of injury a dislocation of the ankle is associated and this must be likewise reduced sati!'factorily. If the inversion force is very violent and associated with plantar flexion the talus becomes rotated 90 degrees about its vertical and long axis as the subtaloid dislocation occurs. If, as the displacing force
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is !>pent, the talus becomes locked in its rotated position, a total dislocation of the talus results. This injury is caused by such extreme force that it is usually compounded. Reduction is secured by reproducing the deformity which caused the injury, namely, inversion and plantar flexion, then by pressure over the posterior surface of the talus thrust backward and inward. Here again, because the talus has been deprived of its soft tissue attachments, and thereby its blood supply, there is grave danger of aseptic necrosis. The leg is immobilized in
Fig. 455.-Complete lateral dislocation at Lisfranc's joint requiring open reduction and removal of fractured fragments between the base of 2nd and 3rd metatarsal.
neutral position in a cast for twelve weeks. Nonweight-bearing is continued for at least six months because of the fear of impeding the slow process of revascularization. Dorsiflexion injuries causing dislocation of the astragalus are always associated with fractures of that bone and have been previously described under fractures of the astragalus. Abduction and adduction injuries cause (1) midtarsal dislocation (Chopart's joint) and (2) tarsometatarsal dislocatiC'n (Lisfranc's joint) .
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In midtarsal dislocations the most frequent injury is the adduction form, and is very often associated with a fracture of the navicular. The medial displacement at the midtarsal joint caused the navicular to be displaced dorsally and medially to the talus and the cuboid medially to the calcis. The history is of a severe wrenching of the foot following a fall from a height. Reduction is obtained by applying traction in the direction of the force which produced the injury. Closed reduction is frequently impossible due to the interposition of the anterior tibial tendon, a capsular ligament or fragments from the fracture of the navicular. Exposure of the talonavicular joint through a dorsomedial incision and the removal of all interposing tissue from the joint space allows the dislocation to be reduced: Position is thereafter maintained by plaster cast immobilization for eight weeks. Dislocation at the tarsometatarsal foint (Lisfranc's joint, Fig. 455) is an injury produced by a fall from a height on a plantar flexed and inverted foot, or a plantar flexed and everted foot. Frequently the dislocation can be reduced by a closed manipulation followed by fixation in plaster. Open reduction is usually required because the interposition of fractured fragments of the base of the metatarsal or cuneiform bones prevents an adequate reduction. When reduction is obtained by surgery, difficulty arises in maintaining the reduction because of the relaxation and tearing of the joint capsules and because the flatness of the joint surfaces allows subluxation to recur. The insertion of a temporary Kirschner wire through the first metatarsalcuneiform joint holds the position nicely, and this is maintained by plaster cast immobilization for six weeks. The Kirschner wire is removed through a small incision. An Unna paste boot is used as a supporting dressing for a short time. METATARSAL FRACTURES
Fractures of the Neck of the Metatarsal.-These fractures occur as the result of direct trauma such as a heavy object falling on the foot. The metatarsal heads are usually displaced into the sole, and if the displacement is not accurately corrected, severe metatarsal discomfort results. If the displacement is not pronounced, it may be reduced by traction applied to the toes by means of a banjo splint incorporated in a plaster boot. The traction is maintained for four weeks. A molded. leather insole with a longitudinal and metatarsal arch pad of sponge rubber is then applied to the foot and weight-bearing is begun. If the displacement is stubborn and does not respond to traction, or if in a case presenting several fractures the impossibility of reducing one of the fractures may compromise the result obtained in others, open reduction is done. At operation skin incisions are made with special care to avoid the pressure points of the foot. A dorsal longitudinal incision is usually made midway between each pair of fractured metatarsals so that two fractures may be exposed with each
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incision. A Kirschner wire is passed as an intramedullary wire through the distal fragment from the fracture line, and with the toe in extreme dorsiflexion is continued through the head of the metatarsal to emerge through the skin overlying the metatarsal head on the plantar surface of the foot. The wire is withdrawn until its proximal end is at the fracture site. The fracture is reduced. A drill is applied to the distal end of the wire, and the wire is guided up the intramedullary space of the proximal fragment to the base of the metatarsal. The distal end of the wire is cut off so that it lies just beneath the skin and can be readily identified. At the end of four weeks a small nick in the skin made under local anesthesia at this site permits the removal of the wire. The molded leather arch support is then fitted to the foot and weight-bearing is commenced. For fractures with very minor displacement the leather archsupporting insole is strapped to the foot with adhesive tape and the patient is permitted to begin weight-bearing immediately. If this results in too much discomfort, a transverse bar is placed under the shoe in a slightly oblique position at a point about 1% inch in front of the heel. This bar eliminates painful pressure on weightbearing. Walking in a plaster cast permits uniform pressure to be distributed throughout the foot and the matatarsal arch becomes flattened out and broadened. With the use of a molded arch support and a transverse shoe bar, normal toe action tends to preserve the normal form and muscle balance of the metatarsal area. Within three weeks the strapping may be removed from the foot and the arch support inserted in the shoe. At the end of the fourth week whirlpool treatments and active exercises are given to increase the mobility of the metatarsophalangeal joints. Avulsion Fracture of the Base of the Fifth Metatarsal Bone.-
This is a common and important fracture. The peroneus brevis tendon is inserted into the base of the fifth metatarsal and a severe inversion strain of the foot throws the entire weight very suddenly on the outside of the foot causing an avulsion of the tendon with a fragment of bone. Local tenderness, swelling and pain, aggravated by inversion of the foot against resistance, follows. Radiographic study shows either an incomplete fracture or a detached fragment from the lateral aspect of the base of the metatarsal. Union in this area is frequently extremely slow. The foot is immobilized in eversion and nonweightbearing is continued for six weeks. March Fractures of the Metatarsals.-A march fracture is a fissure fracture due to stress which commonly occurs in the neck or shaft of the second, third or fourth metatarsal. It occurs during prolonged marching or in speed marching so often called for in basic military training. The predisposing constitutional factors are varus of the first metatarsal, shortening of the first metatarsal, increal!ed flexibility of the first
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metatarsocuneiform joint, and varying degrees of pes cavus. These congenital features lead to the fatigue and exhaustion of the supporting structures of the foot, and the resulting bone stress induced by a long march produces the fracture. The patient customarily notices pain in the forefoot during the long march. This is of a dull, aching, burning character, which slowly increases in intensity, and swelling of the forefoot follows. The patient begins to limp and hold the forefoot rather rigidly. Localized tenderness is present at the fracture site, and pain is experienced upon plantar flexion or traction on the corresponding toe. As the onset of symptoms a roentgenogram of the painful forefoot may be completely negative for fracture. Usually by the tenth day after the initial complaint, there is evidence of a fracture line or some early callus formation. After three weeks the callus forms a spindleshaped mass about the fracture line. The second metatarsal is the one most frequently affected, and, as might be expected, the third is the next most frequently involved. The preventative aspects of treatment should be stressed. The forefoot of the ordinary shoe is very flexible, and slowly it begins to bend upward at the metatarsophalangeal area. Hence, the use of a shoe with a fairly rigid forefoot, and the avoidance of short shoes are measures which will prevent this fracture from occurring. In treating these patients it is, therefore, important to eliminate motion at the metatarsophalangeal joint. This is done by countersinking a steel bar "Y:l inch wide, Ys inch thick and 6 inches long into the sole of the shoe. A soft sponge rubber longitudinal arch pad is inserted into the shoe to balance the foot properly. Whirlpool bath treatments are given regularly until the soreness disappears. After six to eight weeks the fracture is usually healed. The steel bar in the shoe is removed and a small transverse metatarsal bar is substituted, and exercises are given to mobilize the metatarsophalangeal joints. FRACTURES OF THE OS CALCIS
Fractures of the os calcis· account for about 2 per cent of all fractures. They are the most disabling injuries in the realm of fractures. They occur almost exclusively in working men in whom the long period of disability is of vital concern. The injury is due to a fall in the upright position with impact of the heel against the ground. The force of the body weight driving downward causes the talus to be wedged into the calcis, compressing the bone and distorting the subastragalar joint space. Due to the mechanism of the injury a fracture of the spine is so often associated with a fracture of the as calcis that the presence of one injury necessitates the exclusion of the other injury. Clinically the injury is suspected if the patient has sustained a fall
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on his feet from a height and complains of pain in the heel. The heel is extremely tender to pressure. There is marked swelling and ecchymosis. There is noticeable broadening of the heel and very limited painful motion is noted in the subastragalar joint. These fractures fall into three general groups. 1. Isolated fractures without joint injury. These include vertical fractures of the tuberosity, horizontal or "beak" fractures, and fractures of the sustentaculum tali. 2. Comminuted fractures with minimal joint injury, such as the fissure fracture without displacement, and the fracture of the outer wall ahd of the body with reduced tuber-joint angle but no crushing of the joint. 3. Comminuted fractures with severe joint injury causing displacement, ~eduction of the tuber-joint angle with fracture of the outer wall and body, fracture of the posterior and anterior articular surface. Careful roentgenographic study is of extreme importance. A lateral and anteroposterior view of both feet and axial views of both heels are taken. In taking the axial view a strip of gauze bandage is placed in a loop about the anterior arch of the foot with ends held by the patient. The foot is drawn into moderate dorsiflexion. The film is placed underneath the heel and the lower leg. The x-ray tube axis is directed on to the plantar surface of the heel at an angle of 45 degrees. The x-ray will record the amount of comminution, the lateral expansion of the heel, the condition of the talocalcaneal joint, the condition of the sustentaculum tali, the presence or absence of the midtarsal joint subluxation and the tuber-joint angle of the calcaneus. The tuber-joint angle measures the degree of upward displacement of the tuberosity. This is the angle formed by the dorsal surface of the tuberosity with the projected line of the subastragaloid joint. In the normal foot the angle measures about 40 degrees, but when the tuberosity is displaced it is greatly reduced. The principles of treatment as outlined by Bohler are the basis of the current management of these fractures. The tuberosity must be pulled downwards until the tuber-joint angle is restored, and backwards until its full length is regained. This corrects relative lengthening of the calcaneal tendon and reduces the subluxation of the posterior sub astragalar joint. After this has been corrected it is necessary to apply lateral compression to reduce the lateral impaction under the external malleolus and the expansion or lateral displacement of the body of the calcis. Isolated Fractures without Joint Injury.-In the first group of isolated fractures of the calcaneus the following procedures are used. The displacement, if present, in the vertical fracture of the tuberosity, is corrected by a compression clamp. A walking plaster is applied for six weeks and subsequently a gelatin boot for a longer period of time. In the horizontal beak fractures, displacement is corrected by plantar-
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flexing the foot and applying pressure over the upper surface of the fragment. A walking plaster is applied with the ankle in a few degrees of plantar flexion. Plaster is removed after six weeks and an Vnna paste boot applied. Where reduction is not possible and separation continues to be wide, open reduction is done and a screw inserted across the fractured surfaces, thus approximating the fragments. The extremity is immobilized in plaster for six weeks. Fractures of the sustentaculum tali with separation requires the use of lateral compression with a compression clamp followed by plaster cast immobilization in neutral position for six weeks. Comminuted Fractures with Minimal Joint Injury.'-In the second group of calcis fractures those fractures of the body without displacement of the joint surfaces articulating with the talus, in which there is' no crushing of joint surfaces, widening of the tuberosity or reduction of the tuber-joint angle, heal satisfactorily if immobilized in plaster cast for six weeks. To this same group, however, belong 25 per cent of fractures of the os calcis in which there is a fracture of th~ outer wall and body with reduction of the tuber-joint angle. The treatment of this injury requires: (1) lateral compression to prevent impingement under the external malleolus, and (2) plantar traction of the posterior aspect of the os calcis to restore tuber-joint angle. This corrects relative lengthening of the calcaneal tendon and reduces the subluxation of the posterior subastragalar joint. This reduction is accomplished by the Stader splint or the Zimmer reduction frame. The reduction is delayed until primary swelling has begun to subside. Spinal anesthesia is used. The injured leg is compared with the normal one, as a check of the reduction. When the Stader splint is used, a stainless steel pin attached to a V-shaped bar is inserted through the most superior-posterior portion of the os calcis. Two similar pins secured to each other by a pin bar are passed through the lower end of the tibia. Turnbuckle lateral bars connect the pin to the V bar and the activation of the turnbuckle bars brings about distraction and reduces the tuber joint angle to normal. The os calcis is then compressed laterally by the use of a Bohler compression clamp until the width of the os calcis is similar to the width of the normal calcis. X-rays are taken immediately and further adjustments are made if indicated. Exercise of the toes and knee is commenced immediately, and the patient is allowed to be up. Immobilization in the Stader splint is continued for eight weeks. When the splint is removed, nonweight-bearing is continued for a period of four weeks during. which time whirlpool, gentle massage and active exercise are carried out. Weight-bearing is then commenced using a molded arch support, or, if necessary, a transverse bar attached to the shoe, as outlined for metatarsal fractures. The same principles of reduction are used in the Zimmer fracture
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reduction apparatus. A Steinman pin is inserted through the lower ~nd of the tibia, and another through the superior posterior portion of the os calcis. The horseshoes of the apparatus are adjusted to receive each pin. By lowering the distal horseshoe, extension traction can be applied in a downward and backward direction in the long axis of the calcaneus. The os calcis is compressed laterally by a Bohler clamp until the widening of the cal cis has been completely reduced.
Fig. 456.-0ld fracture of the os calcis with aseptic necrosis and traumatic arthritis of the talocalcaneal and calcaneocuboid joints. Triple arthrodesis done to eliminate painful weight-bearing.
Sterile gauze dressings are spiked over the pins, held in place by sheet wadding and a circular cast is applied from below the knee to beyond the toe, incorporating the pins snugly in the cast. Subsequent treatment follows the schedule indicated above. Comminuted Fractures with Severe Joint Injury.-Fifty-five percent of fractures of the os cal cis unfortunately fall into the third group in which the fractures are comminuted with severe joint injury, frac-
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ture of the outer wall and body, reduced tbber-joint angle and displacement and crushing of the posterior articular surface or the anterior articular surface. When the articular surfaces are fragmented and separated a vascular necrosis is due to occur. Because of the painful stiffness of the sub astragalar joint which will eventually result, a triple arthrodesis of the subtalar and midtarsal joints is indicated. In our hands sub astragalar arthrodeses have not been done early because many badly crushed fractures have yielded upon reduction a better functioning foot than x-ray appearances would indicate, and a foot with less permanent disability than would be present with a triple arthrodesis. Hence, in these borderline cases, if weight-bearing proves unsatisfactory following an adequate test of function, a subastragalar arthrodesis is done (Fig. 456). REFERENCES Boyd, H. B. and Knight, R A.: South. M. J., 35:160-167, 1942. Easton, E. R.: J. Bone & Joint Surg., 20: 1053-1056 (Oct.) 1938. Friend, L. F.: U. S. Nav. M. Bull., 40:988-990 (Oct.) 1942. Lipscomb, P. R and Ghormley, R K.: S. CLIN. NORTH AMERICA, 23:995 (Aug.) 1943. Mair, C. B.: Brit. M. J., 2:169 (Aug. 7) 1943. Milch, H.: M. Rec., 155:85-86, 1942; 154:90-92, 1941. Miller, L. F. and Kolb, L. H.: Am. J. Surg., 51:439-441 (Feb. 4) 1941. Morrissey, E. J.: J. Bone & Joint Surg., 28(3): (July) 1946. Morrison, G. M.: Am. J. Surg., 38( 3) :721 (Dec.) 1937. S(;hrock, R D., Johnson, H. F. and Waters, C. H.: J. Bone & Joint Surg., 24(3): 560--573 (July) 1942. Shands, A. R, Jr.: South. M. J., 24:1019, 1931. Shaar, C. M. and Kreuz, F. P., Jr.: Manual of Fractures. Philadelphia, W. B. Saunders Company, 1943. Smith, Hugh: J. Bone & Joint Surg., 19(2):373 (April) 1937. Speed, J. S. and Smith, Hugh: Am. J. Surg., 46:700-710, 1939. Watson-Jones, R: Fractures and Joint Injuries. Baltimore, Williams & Wilkins Co., 1944. Wilson, P. D.: Management of Fractures and Dislocations. Philadelphia, J. B. Lip· pincott Co., 1938.
J.
HAMILTON ALLAN,
M.D.;:'
SPRAINS OF THE FOOT AND ANKLE
THE most common injury to the foot or ankle is a sprain of the lateral ligaments. It is important to differentiate between minimal damage to a ligament and a complete ligamentous rup~ure, for if the latter injury is not recognized and treated adequately healing does not occur and a painful relaxed ankle joint results. The lateral ligaments are composed of (1) the posterior talofibular, (2) the anterior talofibular, and (3) the calcaneofibular ligaments. Moderate swelling, and slight tenderness over the talofibular and calcaneofibular ligaments indicate a simple sprain which may be ideally treated by rest in bed, elevation of extremity, ice packs, early active mobilization, and weight-bearing with the aid of a Gibney boot strapping. Considerable pain, swelling and acute tenderness distal and anterior to the tip of the lateral malleolus aggravated by adducting the foot suggest a ligamentous rupture. The detection of rotation of the talus in the ankle mortis, as the foot is adducted, is additional evidence of a rupture. A radiographic study is made to determine the integrity of the ankle mortis. In a normal anteroposterior roentgenogram of the ankle joint there cannot be a translucent zone between botn talus and tibia and the talus and fibula. If such a zone is visible it indicates damage to the tibiofibular ligament with widening of the ankle mortis. If an anteroposterior roentgenogram of the ankle made with the foot passively adducted shows a luxation of the talus occurring in the ankle mortis (Fig. 454) the lateral ligament is ruptured. This study can be satisfactorily done with the area of injury infiltrated with 1 per cent procaine. If these studies indicate a complete rupture of the lateral ligaments, the hematoma formation is aspirated. Ice bags are applied for twentyfour hours. Hot compresses and the whirlpool bath are then used to reduce the swelling. When this has been relieved, a nonpadded plaster walking cast is applied and maintained for four to six weeks. The removal of the cast is followed by the application of an Unna paste boot or a Gibney boot strapping for ten days. Sprains may occur elsewhere in the foot. Metatarsal sprains are common. There is swelling of the forefoot, acute tenderness under the matatarsal heads, and extreme discomfort upon flexion at the metatarsophalangeal joints. The reCUlrence of this type of sprain is often associated with contraction of the calcaneal tendon and calf " Associate in Orthopedic Surgery, Graduate School of Medicine, University of Pennsylvania; Chief, Orthopedic Services, Germantown and Chestnut Hill Hospitals, Philadelphia.
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muscle. It responds satisfactorily to the application of a felt pad just proximal to the metatarsal heads and a strong adhesive support about the forefoot. When the acute' symptoms subside, a sponge rubber metatarsal support is inserted in the shoe and calf-stretching exercises are begun.
Fig. 454.-Rupture of external ligaments of ankle demonstrated by the marked rotation of the talus in the ankle joint mortis upon inversion of the foot.
FRACTURES AND DISLOCATIONS OF THE ASTRAGALUS
The astragalus (talus) has seven articulating surfaces and articulates with foui bones. It is the only bone in the body that has no muscular attachments. Its surface is largely covered by a nonvascular articular cartilage which responds poorly to trauma. The articular surfices are weight-bearing in function and are involved in all motions of the foot and ankle. The vascular supply of the astragalus is derived from branches of the anterior tibial artery which enter the superior astragalonavicular ligament and supply the superomedial aspect of the neck of the astragalus. The blood supply to the body of the talus is impaired if a fracture ,occurs in the neck proximal to the nutrient artery. Similarly, if the fracture occurs distal to the entrance of the nutrient artery, aseptic necrosis is a possibility. Because of its protected position between the malleoli an injury to the astragalus is rather rare, comprising approximately one fourth of the injuries to the tarsal bones. However, when a fracture occurs the disability may be considerable, because it results not only from the fracture itself but from the serious complications which accompany
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this injury. (1) Aseptic necrosis occurs very frequently because of the inadequate blood supply to the talus. (2) Traumatic arthritis, particularly of the tibiotalar joint, is rather constant because infraction of the cartilaginous joint surfaces is produced as a result of the impacting nature of the force causing the injury, and these cartilaginous surfaces do not heal satisfactorily. (3) Infection of the talus causes marked damage and is a common complication for the reason that so many of these injuries are compound fractures. Fractures of the astragalus are divided into three groups: ( 1) posterior process, (2) the neck, (3) the body. Fracture of the Posterior Process.-The posterior trigonal process is situated lateral to the groove of the flexor hallucis longus tendon and serves as an attachment for the fasciculus of the lateral ligament of the ankle joint. When the foot becomes plantar flexed, the posterior aspect of the talus rises upwards and approaches the lower margin of the posterior surface of the tibia. Impingement of the tibial margin against the posterior process during the action of acute plantar flexion of the foot causes the fracture. Diagnosis is made on the basis of an acute plantar flexion force, localized tenderness, pain with plantar flexion of the foot and on acute flexion of the great toe. The fracture is not a serious one, being outside the joint; however, it is of considerable medicolegal importance because of the necessity of distinguishing between a fracture and the os trigonum. The latter is a developmen,tal variation found in 10 per cent of normal individuals. Roentgen study of a fracture of the posterior process reveals soft tissue s~elling and a sharp irregular fracture surface as contrasted to the smooth regular outline of the os trigonum. The fracture heals satisfactorily with a six week period of fixation in plaster with the foot in neutral position. Fracture of the Neck.-Fracture of the neck of the astragalus is a dorsiflexion injury. It occurs as the neck of the talus is impacted against the anterior margin of the tibia, which is forced downward into the talus causing a vertical fracture. It is unusual to see a vertical fractute of the neck without displacement. So often is it associated with a posterior displacement of the posterior half of the subtalar joint that a fracture of the neck of the talus calls for a careful search for the posterior displacement. If there is no posterior displacement the treatment is immobilization in a cast for eight weeks. If there is the slightest suggestion of posterior displacement of the posterior half of the talus, the foot must be immobilized in plantar flexion and eversion, because only in this position is the alignment of the head and body of the talus to the calcis satisfactory. This position is maintained for eight weeks, then followed by a cast with the foot less dorsiflexed. Three weeks later the foot is brought to the neutral position and plaster immobilization is continued for four weeks.
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Fracture of the Neck of the Talus with Posterior Displacement of the Body.-This is an extreme dorsiflexion injury. Not often seen in civilian life, it proved to be a rather anticipated injury in aircraft accidents during the war. During a crash the rudder pedal forces the foot of the pilot into into acute dorsiflexion, fracturing the neck of the talus with the line of injury extending to the ligaments of the posterior part of the subastragalar joint causing a posterior displacement of the body of the talus. As the body of the talus is displaced, all soft tissue attachments are torn. The bone is thus deprived of its blood supply and avascular necrosis should be anticipated. This type of injury is extremely difficult to reduce. It is imperative to attempt an immediate closed reduction, for the extreme displacement of the body of the talus causes severe pressure on the under surface of the skin, and there is danger of compounding from within. The foot is manipulated into full dorsiflexion, the heel pulled forward, then everted to unlock the sustenaculum tali, and finally, while pressure is maintained on the posterior part of the body of the talus to prevent redisplacement, the foot is brought into plantar flexion. If this manipulation is not successful, open reduction is indicated immediately. A lateral incision along the ankle at the level of the subtalar joint is brought obliquely forward toward the talonavicular joint. The subastragalar joint is exposed, the sustentaculum tali and talus are unlocked and the talus pushed forward into position. The fragments are replaced into position and fixation is secured by directing a Kirschner wire across the fracture line from the head posteriorly into the neck and body and then cut off flush with the neck. Fractures of the Body.-Fractures of the body of the talus are usually comminuted and are accompanied by dislocation of the fragments into the soft parts in front of and behind the ankle. The posterior segment of the body may lodge beside the calcaneal tendon and the anterior segment may be rotated and thrown anteriorly. These fractures cannot be reduced by a closed manipulation and an open reduction should be done as early as the damaged soft parts are in good enough condition for surgery. Here again, after the fragments are replaced into position, fixation is secured by insertion of Kirschner wire or vitallium screw. The incisions are closed without drainage and the extremity is immobilized in a plaster cast for sixteen weeks. In all cases x-rays should be studied carefully for aseptic necrosis, and if it is present, full weight-bearing should be delayed until the bone has a normal appearance. In comminuted fractures of the astragalus, astragalectomy is often done. It should be emphasized that this procedure is attended by serious disability. While it has been successful in a few cases, the majority of results have been disappointing. The technic of astragalectomy was devised for paralytic calcaneovalgus foot where there is usually a muscle weakness in the plantar flexors and adductors of the
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foot. In the traumatic lesions of the talus there is no muscle imbalance. It is difficult to balance the adult foot between the malleoli, and the foot usually goes into varus thus producing a crippling deformity. The best functional results occur from those astragalectomies which will be followed by fusion of the tibia and os calcis. This fusion is to be expected as a sequel to infection, and astragalectomy is performed without hesitation when an infected talus has to be removed before healing will occur. In this event fibrosis or ankylosis occurs limiting the motion between ankle mortis and articulating surface of the os calcis, and if the foot can be maintained in a satisfactory position during the period of fibrosis, a satisfactory foot will result. Occasionally astragalectomy has to be performed where comminution of the talus is extreme. In such instances the foot should be maintained well forward where the anterior margin of the tibia is in a vertical plane with the calcaneocuboid jOint. A calcaneotibial arthrodesis should be done and the foot placed in equinus of 5 degrees in males, and 10 to 15 degrees in females. With the exceptions of the two indications cited above-infection and extreme comminution of the talus-other surgical procedures are preferable to astragalectomy. Where the astragalus has been comminuted, the blood supply seriously disturbed, and the many fracture lines cause a disruption of the articular surfaces, a subastragalar arthrodesis, an ankle fusion or a pantalar arthrodesis may be done. It does not seem reasonable to do these procedures early. The patient should be allowed a test of function for about a year in order to determine which joints should be fused. A surgical arthrodesis of the painful articulations yields a painless and stable weight-bearing foot. Dislocations of the Talus.-Dislocations of the talus are classified by the direction of the displacement. Three distinct groups are evident: (1) supination, (2) dorsiflexion, (3) adduction and abduction. In each group the type of displacement depends upon the force involved. Inversion of the foot causes rupture of the lateral ligament, disloca-. tion of the ankle joint, and if strain continues the interosseous ligament of the subtaloid ruptures allowing the talus to stay in the tibiofibular mortis but the other tarsal bones dislocate inward. This is the subastragaloid dislo~ation. The talus remains in an equinus position. In reducing this dislocation the foot is plantar flexed, then everted and abducted. The ankle is immobilized for six weeks in a walking plaster with the foot in right angled dorsiflexion and neutral lateral position. It must be borne in mind that by the very.nature of injury a dislocation of the ankle is associated and this must be likewise reduced sati!'factorily. If the inversion force is very violent and associated with plantar flexion the talus becomes rotated 90 degrees about its vertical and long axis as the subtaloid dislocation occurs. If, as the displacing force
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is !>pent, the talus becomes locked in its rotated position, a total dislocation of the talus results. This injury is caused by such extreme force that it is usually compounded. Reduction is secured by reproducing the deformity which caused the injury, namely, inversion and plantar flexion, then by pressure over the posterior surface of the talus thrust backward and inward. Here again, because the talus has been deprived of its soft tissue attachments, and thereby its blood supply, there is grave danger of aseptic necrosis. The leg is immobilized in
Fig. 455.-Complete lateral dislocation at Lisfranc's joint requiring open reduction and removal of fractured fragments between the base of 2nd and 3rd metatarsal.
neutral position in a cast for twelve weeks. Nonweight-bearing is continued for at least six months because of the fear of impeding the slow process of revascularization. Dorsiflexion injuries causing dislocation of the astragalus are always associated with fractures of that bone and have been previously described under fractures of the astragalus. Abduction and adduction injuries cause (1) midtarsal dislocation (Chopart's joint) and (2) tarsometatarsal dislocatiC'n (Lisfranc's joint) .
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In midtarsal dislocations the most frequent injury is the adduction form, and is very often associated with a fracture of the navicular. The medial displacement at the midtarsal joint caused the navicular to be displaced dorsally and medially to the talus and the cuboid medially to the calcis. The history is of a severe wrenching of the foot following a fall from a height. Reduction is obtained by applying traction in the direction of the force which produced the injury. Closed reduction is frequently impossible due to the interposition of the anterior tibial tendon, a capsular ligament or fragments from the fracture of the navicular. Exposure of the talonavicular joint through a dorsomedial incision and the removal of all interposing tissue from the joint space allows the dislocation to be reduced: Position is thereafter maintained by plaster cast immobilization for eight weeks. Dislocation at the tarsometatarsal foint (Lisfranc's joint, Fig. 455) is an injury produced by a fall from a height on a plantar flexed and inverted foot, or a plantar flexed and everted foot. Frequently the dislocation can be reduced by a closed manipulation followed by fixation in plaster. Open reduction is usually required because the interposition of fractured fragments of the base of the metatarsal or cuneiform bones prevents an adequate reduction. When reduction is obtained by surgery, difficulty arises in maintaining the reduction because of the relaxation and tearing of the joint capsules and because the flatness of the joint surfaces allows subluxation to recur. The insertion of a temporary Kirschner wire through the first metatarsalcuneiform joint holds the position nicely, and this is maintained by plaster cast immobilization for six weeks. The Kirschner wire is removed through a small incision. An Unna paste boot is used as a supporting dressing for a short time. METATARSAL FRACTURES
Fractures of the Neck of the Metatarsal.-These fractures occur as the result of direct trauma such as a heavy object falling on the foot. The metatarsal heads are usually displaced into the sole, and if the displacement is not accurately corrected, severe metatarsal discomfort results. If the displacement is not pronounced, it may be reduced by traction applied to the toes by means of a banjo splint incorporated in a plaster boot. The traction is maintained for four weeks. A molded. leather insole with a longitudinal and metatarsal arch pad of sponge rubber is then applied to the foot and weight-bearing is begun. If the displacement is stubborn and does not respond to traction, or if in a case presenting several fractures the impossibility of reducing one of the fractures may compromise the result obtained in others, open reduction is done. At operation skin incisions are made with special care to avoid the pressure points of the foot. A dorsal longitudinal incision is usually made midway between each pair of fractured metatarsals so that two fractures may be exposed with each
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incision. A Kirschner wire is passed as an intramedullary wire through the distal fragment from the fracture line, and with the toe in extreme dorsiflexion is continued through the head of the metatarsal to emerge through the skin overlying the metatarsal head on the plantar surface of the foot. The wire is withdrawn until its proximal end is at the fracture site. The fracture is reduced. A drill is applied to the distal end of the wire, and the wire is guided up the intramedullary space of the proximal fragment to the base of the metatarsal. The distal end of the wire is cut off so that it lies just beneath the skin and can be readily identified. At the end of four weeks a small nick in the skin made under local anesthesia at this site permits the removal of the wire. The molded leather arch support is then fitted to the foot and weight-bearing is commenced. For fractures with very minor displacement the leather archsupporting insole is strapped to the foot with adhesive tape and the patient is permitted to begin weight-bearing immediately. If this results in too much discomfort, a transverse bar is placed under the shoe in a slightly oblique position at a point about 1% inch in front of the heel. This bar eliminates painful pressure on weightbearing. Walking in a plaster cast permits uniform pressure to be distributed throughout the foot and the matatarsal arch becomes flattened out and broadened. With the use of a molded arch support and a transverse shoe bar, normal toe action tends to preserve the normal form and muscle balance of the metatarsal area. Within three weeks the strapping may be removed from the foot and the arch support inserted in the shoe. At the end of the fourth week whirlpool treatments and active exercises are given to increase the mobility of the metatarsophalangeal joints. Avulsion Fracture of the Base of the Fifth Metatarsal Bone.-
This is a common and important fracture. The peroneus brevis tendon is inserted into the base of the fifth metatarsal and a severe inversion strain of the foot throws the entire weight very suddenly on the outside of the foot causing an avulsion of the tendon with a fragment of bone. Local tenderness, swelling and pain, aggravated by inversion of the foot against resistance, follows. Radiographic study shows either an incomplete fracture or a detached fragment from the lateral aspect of the base of the metatarsal. Union in this area is frequently extremely slow. The foot is immobilized in eversion and nonweightbearing is continued for six weeks. March Fractures of the Metatarsals.-A march fracture is a fissure fracture due to stress which commonly occurs in the neck or shaft of the second, third or fourth metatarsal. It occurs during prolonged marching or in speed marching so often called for in basic military training. The predisposing constitutional factors are varus of the first metatarsal, shortening of the first metatarsal, increal!ed flexibility of the first
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metatarsocuneiform joint, and varying degrees of pes cavus. These congenital features lead to the fatigue and exhaustion of the supporting structures of the foot, and the resulting bone stress induced by a long march produces the fracture. The patient customarily notices pain in the forefoot during the long march. This is of a dull, aching, burning character, which slowly increases in intensity, and swelling of the forefoot follows. The patient begins to limp and hold the forefoot rather rigidly. Localized tenderness is present at the fracture site, and pain is experienced upon plantar flexion or traction on the corresponding toe. As the onset of symptoms a roentgenogram of the painful forefoot may be completely negative for fracture. Usually by the tenth day after the initial complaint, there is evidence of a fracture line or some early callus formation. After three weeks the callus forms a spindleshaped mass about the fracture line. The second metatarsal is the one most frequently affected, and, as might be expected, the third is the next most frequently involved. The preventative aspects of treatment should be stressed. The forefoot of the ordinary shoe is very flexible, and slowly it begins to bend upward at the metatarsophalangeal area. Hence, the use of a shoe with a fairly rigid forefoot, and the avoidance of short shoes are measures which will prevent this fracture from occurring. In treating these patients it is, therefore, important to eliminate motion at the metatarsophalangeal joint. This is done by countersinking a steel bar "Y:l inch wide, Ys inch thick and 6 inches long into the sole of the shoe. A soft sponge rubber longitudinal arch pad is inserted into the shoe to balance the foot properly. Whirlpool bath treatments are given regularly until the soreness disappears. After six to eight weeks the fracture is usually healed. The steel bar in the shoe is removed and a small transverse metatarsal bar is substituted, and exercises are given to mobilize the metatarsophalangeal joints. FRACTURES OF THE OS CALCIS
Fractures of the os calcis· account for about 2 per cent of all fractures. They are the most disabling injuries in the realm of fractures. They occur almost exclusively in working men in whom the long period of disability is of vital concern. The injury is due to a fall in the upright position with impact of the heel against the ground. The force of the body weight driving downward causes the talus to be wedged into the calcis, compressing the bone and distorting the subastragalar joint space. Due to the mechanism of the injury a fracture of the spine is so often associated with a fracture of the as calcis that the presence of one injury necessitates the exclusion of the other injury. Clinically the injury is suspected if the patient has sustained a fall
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on his feet from a height and complains of pain in the heel. The heel is extremely tender to pressure. There is marked swelling and ecchymosis. There is noticeable broadening of the heel and very limited painful motion is noted in the subastragalar joint. These fractures fall into three general groups. 1. Isolated fractures without joint injury. These include vertical fractures of the tuberosity, horizontal or "beak" fractures, and fractures of the sustentaculum tali. 2. Comminuted fractures with minimal joint injury, such as the fissure fracture without displacement, and the fracture of the outer wall ahd of the body with reduced tuber-joint angle but no crushing of the joint. 3. Comminuted fractures with severe joint injury causing displacement, ~eduction of the tuber-joint angle with fracture of the outer wall and body, fracture of the posterior and anterior articular surface. Careful roentgenographic study is of extreme importance. A lateral and anteroposterior view of both feet and axial views of both heels are taken. In taking the axial view a strip of gauze bandage is placed in a loop about the anterior arch of the foot with ends held by the patient. The foot is drawn into moderate dorsiflexion. The film is placed underneath the heel and the lower leg. The x-ray tube axis is directed on to the plantar surface of the heel at an angle of 45 degrees. The x-ray will record the amount of comminution, the lateral expansion of the heel, the condition of the talocalcaneal joint, the condition of the sustentaculum tali, the presence or absence of the midtarsal joint subluxation and the tuber-joint angle of the calcaneus. The tuber-joint angle measures the degree of upward displacement of the tuberosity. This is the angle formed by the dorsal surface of the tuberosity with the projected line of the subastragaloid joint. In the normal foot the angle measures about 40 degrees, but when the tuberosity is displaced it is greatly reduced. The principles of treatment as outlined by Bohler are the basis of the current management of these fractures. The tuberosity must be pulled downwards until the tuber-joint angle is restored, and backwards until its full length is regained. This corrects relative lengthening of the calcaneal tendon and reduces the subluxation of the posterior sub astragalar joint. After this has been corrected it is necessary to apply lateral compression to reduce the lateral impaction under the external malleolus and the expansion or lateral displacement of the body of the calcis. Isolated Fractures without Joint Injury.-In the first group of isolated fractures of the calcaneus the following procedures are used. The displacement, if present, in the vertical fracture of the tuberosity, is corrected by a compression clamp. A walking plaster is applied for six weeks and subsequently a gelatin boot for a longer period of time. In the horizontal beak fractures, displacement is corrected by plantar-
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flexing the foot and applying pressure over the upper surface of the fragment. A walking plaster is applied with the ankle in a few degrees of plantar flexion. Plaster is removed after six weeks and an Vnna paste boot applied. Where reduction is not possible and separation continues to be wide, open reduction is done and a screw inserted across the fractured surfaces, thus approximating the fragments. The extremity is immobilized in plaster for six weeks. Fractures of the sustentaculum tali with separation requires the use of lateral compression with a compression clamp followed by plaster cast immobilization in neutral position for six weeks. Comminuted Fractures with Minimal Joint Injury.'-In the second group of calcis fractures those fractures of the body without displacement of the joint surfaces articulating with the talus, in which there is' no crushing of joint surfaces, widening of the tuberosity or reduction of the tuber-joint angle, heal satisfactorily if immobilized in plaster cast for six weeks. To this same group, however, belong 25 per cent of fractures of the os calcis in which there is a fracture of th~ outer wall and body with reduction of the tuber-joint angle. The treatment of this injury requires: (1) lateral compression to prevent impingement under the external malleolus, and (2) plantar traction of the posterior aspect of the os calcis to restore tuber-joint angle. This corrects relative lengthening of the calcaneal tendon and reduces the subluxation of the posterior subastragalar joint. This reduction is accomplished by the Stader splint or the Zimmer reduction frame. The reduction is delayed until primary swelling has begun to subside. Spinal anesthesia is used. The injured leg is compared with the normal one, as a check of the reduction. When the Stader splint is used, a stainless steel pin attached to a V-shaped bar is inserted through the most superior-posterior portion of the os calcis. Two similar pins secured to each other by a pin bar are passed through the lower end of the tibia. Turnbuckle lateral bars connect the pin to the V bar and the activation of the turnbuckle bars brings about distraction and reduces the tuber joint angle to normal. The os calcis is then compressed laterally by the use of a Bohler compression clamp until the width of the os calcis is similar to the width of the normal calcis. X-rays are taken immediately and further adjustments are made if indicated. Exercise of the toes and knee is commenced immediately, and the patient is allowed to be up. Immobilization in the Stader splint is continued for eight weeks. When the splint is removed, nonweight-bearing is continued for a period of four weeks during. which time whirlpool, gentle massage and active exercise are carried out. Weight-bearing is then commenced using a molded arch support, or, if necessary, a transverse bar attached to the shoe, as outlined for metatarsal fractures. The same principles of reduction are used in the Zimmer fracture
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reduction apparatus. A Steinman pin is inserted through the lower ~nd of the tibia, and another through the superior posterior portion of the os calcis. The horseshoes of the apparatus are adjusted to receive each pin. By lowering the distal horseshoe, extension traction can be applied in a downward and backward direction in the long axis of the calcaneus. The os calcis is compressed laterally by a Bohler clamp until the widening of the cal cis has been completely reduced.
Fig. 456.-0ld fracture of the os calcis with aseptic necrosis and traumatic arthritis of the talocalcaneal and calcaneocuboid joints. Triple arthrodesis done to eliminate painful weight-bearing.
Sterile gauze dressings are spiked over the pins, held in place by sheet wadding and a circular cast is applied from below the knee to beyond the toe, incorporating the pins snugly in the cast. Subsequent treatment follows the schedule indicated above. Comminuted Fractures with Severe Joint Injury.-Fifty-five percent of fractures of the os cal cis unfortunately fall into the third group in which the fractures are comminuted with severe joint injury, frac-
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ture of the outer wall and body, reduced tbber-joint angle and displacement and crushing of the posterior articular surface or the anterior articular surface. When the articular surfaces are fragmented and separated a vascular necrosis is due to occur. Because of the painful stiffness of the sub astragalar joint which will eventually result, a triple arthrodesis of the subtalar and midtarsal joints is indicated. In our hands sub astragalar arthrodeses have not been done early because many badly crushed fractures have yielded upon reduction a better functioning foot than x-ray appearances would indicate, and a foot with less permanent disability than would be present with a triple arthrodesis. Hence, in these borderline cases, if weight-bearing proves unsatisfactory following an adequate test of function, a subastragalar arthrodesis is done (Fig. 456). REFERENCES Boyd, H. B. and Knight, R A.: South. M. J., 35:160-167, 1942. Easton, E. R.: J. Bone & Joint Surg., 20: 1053-1056 (Oct.) 1938. Friend, L. F.: U. S. Nav. M. Bull., 40:988-990 (Oct.) 1942. Lipscomb, P. R and Ghormley, R K.: S. CLIN. NORTH AMERICA, 23:995 (Aug.) 1943. Mair, C. B.: Brit. M. J., 2:169 (Aug. 7) 1943. Milch, H.: M. Rec., 155:85-86, 1942; 154:90-92, 1941. Miller, L. F. and Kolb, L. H.: Am. J. Surg., 51:439-441 (Feb. 4) 1941. Morrissey, E. J.: J. Bone & Joint Surg., 28(3): (July) 1946. Morrison, G. M.: Am. J. Surg., 38( 3) :721 (Dec.) 1937. S(;hrock, R D., Johnson, H. F. and Waters, C. H.: J. Bone & Joint Surg., 24(3): 560--573 (July) 1942. Shands, A. R, Jr.: South. M. J., 24:1019, 1931. Shaar, C. M. and Kreuz, F. P., Jr.: Manual of Fractures. Philadelphia, W. B. Saunders Company, 1943. Smith, Hugh: J. Bone & Joint Surg., 19(2):373 (April) 1937. Speed, J. S. and Smith, Hugh: Am. J. Surg., 46:700-710, 1939. Watson-Jones, R: Fractures and Joint Injuries. Baltimore, Williams & Wilkins Co., 1944. Wilson, P. D.: Management of Fractures and Dislocations. Philadelphia, J. B. Lip· pincott Co., 1938.