+FRACTURES, DISLOCATIONS AND SPRAINS+
+FRACTURES+
A fracture may be defined as a broken bone. Fractures are classified
as follows:
1. As to their degree.
2. As to the direction of the line of fracture.
3. As to their location.
4. As to the etiology.
5. As to their relation to the overlying skin.
6. As to the number of fragments.
7. As to whether they are complicated or not.
+Degree of Fracture.+ A fracture which only involves a portion of the
thickness of the bones, so that its continuity has not been entirely
lost or a fragment has not been completely detached, is called an
_incomplete fracture_. A fracture which involves the entire thickness
of the bone, so that it is divided into two or more distinct
fragments, is called a _complete fracture_.
+INCOMPLETE FRACTURES+
Among the varieties of incomplete fracture are: greenstick; fissured;
depressed.
+Greenstick Fractures+ (really a bending rather than a break of the
bone) are mostly seen under the age of fifteen, and the bones of the
leg are rarely affected.
+Fissured Fractures+ are those in which there is a split or crack in the
bones; they are very rare in the bones of the lower extremity.
+Depressed Fractures+ are fractures in which one or more segments of
broken bone are depressed; they are most common in fractures of the
skull.
+COMPLETE FRACTURES+
+Complete Fractures+ are divided according to the line and the seat of
the breech of bone continuity.
DIRECTIONS OF THE LINES OF FRACTURES
+Transverse+, when the line of fracture does not deviate more than ten
to fifteen degrees from that of the transverse axis. This variety is
rare in the shaft of the long bones. It is usually found at the lower
end of the radius or of the femur, and in the short bones.
+Longitudinal+, when the break is parallel to the long diameter of the
bone; very few cases of this variety are seen.
+Oblique+, when the direction of the line of fracture may form any angle
with the transverse axis of the bone up to a right angle. When it
approaches the latter, it belongs to the group of longitudinal
fractures. In the oblique variety, the line of fracture may be single
or multiple. This and the spiral form are most frequent in the shafts
of the long bones.
+Spiral+, when the break line is spiral. This variety of fracture was
formerly considered to be very rare. The more systematic use of the
X-ray as part of the routine of diagnosis has shown that spiral
fractures are quite frequent in the shafts of the tibia and fibula.
They are usually the result of a rotating or twisting force.
CLASSIFICATION OF FRACTURES
+Comminuted+, when there is extensive splintering of the bone adjoining
the fracture or one of the fragments.
+Impacted+, when the fragments are driven into each other. This variety
usually occurs in the neck of the femur.
+Compression, or Crushing Fractures+, when the broken bones are
compressed or crushed; this variety usually occurs in the tarsal
bones. The spongy portion and cortical layer are both crushed. In some
cases there is a perfect pulpification of these bones. This condition
occurs after falls from a height upon the sole of the foot.
LOCATION OF FRACTURE
+In the Diaphysis of a Bone.+ Breaks in the diaphysis of a bone are
spoken of as fractures of the _shaft_, and to be still more exact, it
is stated whether of the upper, middle, or lower third.
+At the Ends of Bones.+ Fractures occurring at the ends of bones receive
the name of the part which the line of fracture transverses; for
example, fractures of the _neck_ of a bone, of a _tuberosity_, of a
_process_, of a _condyle_, etc.
There are two forms of fracture that require special mention in
connection with their location. These are _epiphyseal separations_ and
_articular fractures_.
+Epiphyseal Separations.+ The union of the epiphysis to the diaphysis
commences during puberty, hence these fractures are less common in
childhood than after the ages of eleven or twelve. As a rule, they can
only occur before the twentieth year. The periosteum is more resisting
and tougher during the early years of life than later on.
+Articular Fracture+ (_joint fractures_). Like epiphyseal separations,
recognition and proper treatment of these fractures have assumed great
importance.
Articular fractures may be divided into three classes:
1. _Intra-articular._ In these the line of fracture lies
entirely within the joint. Such fractures are most frequently
found in the elbow and knee joint.
2. _Para articular._ In these the line of fracture extends
close to the joint but not into it. An example of this class
is the _supracondyloid_ fracture of the humerus.
3. _Articular fractures proper._ The majority of joint
fractures belong to this class. The line of fracture either
extends into the joint from without or it extends from the
joint outward. As example, the ankle joint; the majority of
the typical supramalleolar, malleolar, and spiral fractures of
the tibia and fibula.
+Etiology.+ Fractures may be divided into two groups: the _traumatic_
and the _pathologic_ or _spontaneous_. In the traumatic, the fracture
is the result of violence acting upon a bone which is either normal or
shows slight changes due to the physiologic causes mentioned. A
pathologic or spontaneous fracture is one which occurs in a bone, the
strength of which has been diminished by some preceding abnormal or
pathologic changes. In this variety the degree of force which produced
the fracture would not be sufficient to cause a fracture in a healthy
bone.
The causes of traumatic fractures may be either predisposing or
exciting.
+Predisposing Causes.+ The bones of the human body attain their greatest
strength toward middle age. From infancy up to that time the bones are
very elastic and yielding. Toward old age an interstitial atrophy
occurs. It causes a thinning of the cortex of the shafts and of the
trabeculae of the spongy portions of the long and short bones. It is
an actual diminution of the bone substance and a corresponding
increase of the fat. This is especially seen in the neck of the femur.
When it occurs in old age, it acts as a predisposing cause, but when
it occurs prematurely or reaches an extreme degree, it must be
considered as pathologic.
EXISTING OR DETERMINING CAUSES OF FRACTURES
+Fractures by External Violence+ are divided both clinically and from a
mechanic standpoint into two classes: _direct_ and _indirect_. In
fractures by direct violence the bone breaks immediately under the
point where the force has been applied. In this class of fractures
there is more damage to the soft tissues and this damage is generally
more serious than in indirect fractures. Direct fractures are more
likely to occur in exposed bones like the clavicle, os calcis, etc.
An example of fracture by direct violence is found in fractures of the
tarsal bones after a fall upon the feet from a height.
Under the head of fractures by indirect violence belong (a) those
which occur as the result of a rotary or twisting force (spiral
fracture of the tibia or fibula, for example); (b) those which are
produced by compression; (for example, a fall upon the feet may cause
an impacted fracture of the upper end of the tibia); (c) those which
are the result of a tearing force.
Fractures resulting from a tearing force occur when a joint is
suddenly moved beyond its normal range of excursion. The firmly
attached ligaments being a fixed point, the ends or some process of
the bones composing the joint are torn off from the remainder of the
bone. Examples of this are fractures of the internal or external
malleoli, following forcible eversion or inversion of the foot.
Fractures are also caused by muscular action and by gunshot injuries.
+Pathologic+ (spontaneous fractures):
1. Fractures resulting from bone fragility of local origin as
for example, tumors, osteomyelitis, aneurisms.
2. Fractures resulting from bone fragility due to some general
disease, as for example, tabes dorsalis, paresis, rachitis,
osteomalacia, and exhausting chronic diseases.
CLASSIFICATION AND RELATION OF FRACTURES TO THE OVERLYING SKIN
Fractures are divided into _compound_, or _open_ and _simple_, or
_subcutaneous_, according to whether a communication does or does not
exist between the seat of fracture and a wound of the skin.
A compound fracture is one in which the cutaneous wound communicates
with the seat of the fracture.
A simple fracture is one in which a wound of the skin is absent, or,
if present, no communication exists between it and the seat of the
fracture.
The majority of compound fractures are the result of direct violence,
and the injuries of the soft parts, are, as a rule, far more extensive
and serious than in a simple fracture. A fracture which is simple at
first, may become compound as a result of necrosis of the skin lying
over it; or as a consequence of the original injury; or of pressure
upon it by a displaced fragment; or by penetration of the skin, in
efforts to use the limb.
FURTHER CLASSIFICATION OF FRACTURES
+Fracture.+ In the ordinary use of the term “fracture” is understood to
indicate a _complete_ or _incomplete_ separation of the bone into two
or more fragments, the lines of which are continuous with each other.
+Multiple Fracture.+ The term _multiple fracture_ is applied to the
simultaneous fracture of two or more non-adjacent bones, and also to
those cases in which two or more fractures of the same bone exist, and
the lines are not continuous with each other. Such multiple fractures
are usually the result of direct violence.
+Complicated Fracture.+ When a fracture is accompanied by injuries of
the viscera, nerves, etc., the term _complicated fracture_ is applied.
Such a fracture may be simple or compound. The term complicated, as
ordinarily employed, is limited to those fractures which are
accompanied by local, rather than by general complications.
+Symptoms of a Recent Fracture.+ In the examination of a patient who has
sustained a recent fracture, procedure should be as follows: the
history of the patient and of the accident should be taken; an
examination should be made for objective signs, like deformity,
abnormal mobility, crepitus, and ecchymosis; subjective symptoms, such
as pain and loss of function of the limb should be ascertained; an
X-ray picture should be taken and every possible precaution observed
to exclude distortion or exaggeration.
+Treatment of Fractures.+ _First Aid._ The treatment of fracture may be
said to begin from the moment of its occurrence. Much can be done for
the comfort of the patient and correct union of the fracture by
intelligent treatment during the first hours.
The proper temporary fixation of the limb, the mode of transportation,
and the removal of the clothing, all require special mention.
The use of first aid dressings, those which can be used until more
permanent and suitable ones can be applied, varies, of course, with
the individual bone affected. In fractures of the tibia, fibula and
foot, as well as in those of the lower half of the femur, the use of
the blanket splint will be found of great aid. Instead of a blanket, a
long pillow or soft cushion can be employed in the same manner.
The “blanket splint” can be readily made by folding a blanket in such
a manner that it extends from the middle of the injured thigh to below
the foot. Two pieces of narrow, strong board, or better still, two
broomsticks are rolled up in the blanket, one at either end. The
rolled-up blanket is now turned in so that the board supports with
their enveloping turns of blanket, lie upon the posterior surface.
Thus, a trough is formed in which the limb is placed and firmly
secured by loops of bandage, one below the foot, the second just above
the ankle, the third below the knee, and the fourth near the upper end
of the blanket.
In fractures of the leg, after the application of the emergency
splint, the patient should be transported in a recumbent position, the
support being as firm as possible, a wide board, shutter or a wooden
rail being preferable. If such supports are not at hand, and the
patient is to be moved without their use, the persons transporting the
invalid should be distributed in the following manner: one supporting
the head and shoulders, a second the pelvis, and the third the two
limbs.
+Reduction.+ The reduction of a fracture is the effort made by the
surgeon to overcome any tendency to displacement, and thus to place
the fragments in such close apposition that an accurate and firm union
is possible. The best time in general for the reduction of a fracture
is as soon as possible after the accident, if the patient’s general
condition will permit. If there is marked displacement of fragments,
so that there is danger of necrosis of the overlying skin or of damage
to the adjacent vessels or nerves, an early reduction is imperative.
In all cases in which reduction is very painful or difficult, whether
performed shortly after the accident or at a later period, it is best
to administer an anesthetic to overcome muscular contraction and to
decrease the amount of pain. After reduction of a fracture, retentive
apparatus is indicated in order to maintain apposition. In the use of
dressings there will be two kinds, those which are temporary and those
which are permanent. The former are employed where the swelling of the
limb is such that some dressing can be employed which will not cause
pressure.
Certain general principles should be followed in the use of splints;
for instance, a splint, after being applied, should not interfere with
the circulation, allowance always being made for the swelling of the
limb, which almost invariably occurs during the first week. The
splint, if flat, should be wide enough to obviate the possibility of
pressure against the point of fracture; also, it should project a
little beyond the limb.
In general, it is best to immobilize the adjacent joints, above and
below the seat of fracture, but no dressing should be permitted to
remain so long as to produce stiffness of the joints and muscular
atrophy.
The skin, even in simple fractures, must be cleansed with green soap,
water and alcohol. If blebs or an area of threatening necrosis of the
skin exist, they should be freely dusted with powdered boric acid and
a few layers of aseptic gauze applied.
The form of retentive apparatus to be employed will vary, of course,
with the individual bone requiring treatment.
The most important articles of a fracture equipment are as follows:
1. Plaster of Paris bandages for making molded splints and
circular casts.
2. A stock of basswood, three-sixteenths of an inch thick, for
making wooden splints.
3. An assortment of metal splints or materials for making
them.
4. Muslin for bandages and slings.
5. Five yard rolls of ordinary and zinc oxide adhesive
plaster, three inches wide.
6. Cotton batting and sheet wadding for padding splints.
7. Strips of tin or thin cypress for strengthening plaster
casts.
The selection of a dressing for the immobilization of a fracture
depends upon, _first_, the particular bone involved and whether
apposition can be maintained with or without extension; _second_,
whether great swelling be present or not; _third_, whether the
fracture be simple or compound; and _last_, whether ambulatory
treatment be preferable to that in the recumbent position. This latter
applies, of course, only to fractures of the lower extremity.
+Operative Treatment of Simple Fractures.+ Operative treatment of a
recent simple fracture is indicated in general, when reduction cannot
be completely made; when correct apposition cannot be maintained; when
there is interposition of bone or soft parts; when the fracture is a
spiral one with considerable displacement of the fragments; when
fragments are rotated upon each other, and when there are multiple
fractures.
The most favorable time to operate in recent simple fractures is at
the end of the first or beginning of the second week. At this time the
process of callus formation is most active. The blood clots and loose
shreds of tissue have begun to be absorbed, so that the fragments are
more easily accessible.
+Methods of Fixation of the Fragments.+ In the majority of cases the
reposition of the fragments alone is not sufficient to maintain
accurate apposition. It is usually necessary to employ some means of
mechanical fixation. In all the methods employed, the preparation of
the parts is the same as for any aseptic operation. The opportunity
for serious complications resulting from septic infection, is greater
than in any other class of operations. It is for this reason that
extraordinary caution must be exercised. The incision should be large
enough to expose the seat of the fracture thoroughly.
The materials used to secure fixation are: absorbable sutures, such as
chromicized catgut or kangaroo tendon; metal suture of silver or
bronze aluminum wire; screws, nails, plates, clamps, etc.
+Injuries in the Vicinity of the Ankle Joint.+ In the examination of a
patient who shows evidence of injury in the vicinity of the ankle
joint, such as swelling, deformity, loss of function, etc., the
following conditions must be thought of, in the order given:
1. Fractures of the lower ends of the tibia and fibula
(Pott’s Fracture).
2. Dislocation at or near the ankle.
3. Fractures of the tarsal bones.
4. Rupture of the tendon Achillis.
5. Sprains of the ankle.
+Fractures of the Lower Ends of the Tibia and Fibula.+ Commonly given
the name of _Pott’s Fracture_. They may be the result either of
forcible abduction or eversion of the foot, or of inversion or
adduction. If the sole or main movement is eversion, the _internal_
malleolus is broken, and if the force continues to act, it also causes
the _external_ malleolus to be broken. In the second variety, fracture
by inversion, the first effect of the force is to break the fibula at
the external malleolus. If the movement continues, the internal
malleolus or a greater portion of the tibia is broken off.
+Diagnosis.+ The diagnosis is usually easy to make. The ankle joint is
greatly swollen, the depression, normally present in front of and
behind the malleoli, being obliterated. The foot is displaced outward,
and the internal malleolus is prominent. This deformity will often
persist and become a cause of disability after healing of the
fracture.
There is also backward displacement of the foot. These displacements
may be so marked as, at first glance, to resemble a true dislocation
of the ankle.
Abnormal lateral and anteroposterior mobility may be ascertained by
grasping the sole of the foot with one hand and moving it inward and
outward, or backward and forward, while the other hand steadies the
leg. There is great tenderness between the tibia and fibula at the
front of the ankle, and over the points of fracture in the malleoli.
If the fibula alone be broken, abnormal mobility and crepitus may be
elicited by pressing its tip inward with the index finger of the one
hand while a finger of the other hand is placed at the seat of
fracture.
In some cases of Pott’s fracture the foot will move inward instead of
outward. The degree of outward displacement can be measured by the
difference in the distance from the front of the ankle to the cleft
between the first and second toes, as measured on the sound and
injured foot. There is not always complete loss of function. In
fractures of the external malleolus alone, the patient may walk quite
well.
+Treatment of Fractures of the Leg.+ The treatment of a simple fracture
of one or of both bones of the leg depends _first_, upon whether or
not swelling is present, and _second_, upon the amount of displacement
of fragments and our ability to keep them in apposition after
reduction. If the case is seen within a few hours after the injury and
but little, if any, swelling be present, the following is a perfectly
safe and justifiable method of treatment:
The limb is wrapped with strips of sheet-wadding from the toes to the
middle of the thigh, and a circular plaster of Paris cast is applied
extending over the same area. Before the cast is dry, it is cut open
along the median line, in front, to allow for any swelling. The cast
is best applied while the patient is under the influence of an
anesthetic, so as to permit reduction of the fragments by traction
upon the foot. In from ten days to two weeks the cast should be
removed and a fresh one applied. The second cast does not require to
be cut open, and can be left on the limb until the end of the fourth
week. It is then removed and if union be complete, no further cast
need be worn. Massage of the limb and passive and active motion are
now begun.
+Fractures of the Tarsal Bones.+ Fractures of these bones have been
found far more frequently than was thought before the use of the
X-ray. Many cases of tarsal fracture have been treated for sprains of
the ankle. It is only when the recovery is slow or the injury is
followed by a traumatic flat foot that the surgeon begins to suspect
that a more serious condition was present at the time of the original
injury.
The astragalus and os calcis are the tarsal bones that are usually
affected. Fractures of the os calcis, in the majority of cases, are
due to compression. The patient falls from a height to the ground, on
a hard substance. The os calcis is crushed between the astragalus and
the ground.
There are three general types of fracture of the os calcis:
1. That in which the fracture has been confined largely to
that portion lying behind a vertical plane through the middle
of the body of the astragalus. There are three varieties of
this heel fragment type: (_a_) cases with one large heel
fragment; (_b_) cases of small heel fragments (in this
variety, also called avulsion fracture, the sudden contraction
of the calf muscles pulls the fragment off; at times the tendo
Achillis itself is torn off from the attachment to the os
calcis at the same time); (_c_) cases showing only fissures in
the bone.
2. Comminution of the anterior half of the os calcis.
3. All the cases of extensive comminution of the bones; the
bone is literally shattered.
+Fractures of the Astragalus.+ These can be divided into: (_a_) those of
the neck; (_b_) those of the body. The former are the most common
fractures of the astragalus. They may follow sudden dorsal flexion, or
forced supination, or pronation of the foot. They may be due to a fall
from a height or from direct violence. Fractures of the body of the
astragalus are usually the result of a crushing force which ordinarily
have a like effect on the body of the os calcis, and are often
associated with fractures of the latter bone. The variety of fractures
is considerable, varying from two large fragments, to complete
comminution of the bone.
A fact of considerable importance in the interpretation of skiagraphs
of fractures of the astragalus, is a knowledge of the presence in many
normal individuals of a little bone known as the _os trigonum_. It may
occur detached from the astragalus or may be attached to it as a
process, on its posterior aspect, and on account of the swelling and
pain around the ankle, a diagnosis can seldom be made without the
routine use of the X-ray in every injury in this region.
The swelling, with obliteration of the depressions normally present
around the ankle, does not differ from that characteristic of a sprain
of the ankle or of a Pott’s fracture. If there is extensive
comminution of the os calcis or astragalus, the malleoli may be a
little lower than normal.
The X-ray must always remain our most reliable means of diagnosis at
the time of the injury. At a later period the chief symptoms are a
painful flat foot, ankylosis of the ankle joint, pain and difficulty
in pronating and supinating the foot.
The prognosis of fractures of the tarsal bones is not favorable, even
though the lesion has been recognized at the time of injury. Even in
the most favorable cases there is some limitation of lateral motion.
The outlook is better in those cases of fracture of the os calcis in
which there is a large heel fragment, than if the fracture is
comminuted. The most frequent sequel is stiffness of the ankle-joint
and traumatic pes valgus. Infection is frequent in compound fractures.
+Treatment.+ This does not differ from that of a Pott’s fracture until
the greater part of the swelling has disappeared. The skin of the foot
and lower portion of the leg should be thoroughly cleansed and covered
with gauze. This is necessary on account of the possibility of
necrosis of the skin of the heel, and the danger of infection of the
bruised soft tissues around the heel.
The foot should be placed in a well-padded box or in a posterior
splint of the Volkman type. Ice bags should be applied over the sides
of the heel.
After from eight to ten days, a circular plaster cast can be applied,
extending from the toes to the knee. An anesthetic should be given
during the application of the cast, the foot being held flexed at
right angles and sheet wadding freely used around the ankle. The cast
should be worn for seven weeks. At the end of this time the patient is
gradually permitted to step upon the injured foot. Passive and active
motion are also now employed.
Fractures of the neck of the astragalus, with rotation of the
posterior fragment, are usually followed by great limitation of the
movements of the ankle joint. This condition might be greatly improved
by an open operation.
+Fractures of the Metatarsal Bones.+ These are usually due to direct
violence, as occurs when a heavy weight falls upon the dorsum of the
foot. Another example of direct violence is a fracture following a
crushing injury, as in being run over.
In indirect violence, such as follows dancing, jumping, or sudden
twists of the foot, the fifth metatarsal bone is the one most often
involved. There is but little tendency to displacement except when
several bones are broken at the same time, and then it is toward the
dorsum of the foot.
The diagnosis in fractures produced by direct violence is made from
the following: presence of severe localized pain; swelling; and, not
infrequently, crepitus and abnormal mobility. In those fractures due
to indirect violence (second, third and fifth metatarsals), there is
pain when the patient endeavors to put pressure upon the toes or tries
to invert the foot. The usual signs of fracture are absent. A
skiagraph should be made in every case.
Fracture of the metatarsal bones is liable to be followed by traumatic
flat foot, on account of the sinking of the arch, or painful large
calluses forming on the sole of the foot may interfere with walking.
+Treatment.+ The treatment in such fractures is by immobilization in a
posterior metal or plaster splint, for four weeks. If there is
continual pain upon walking after the injury, a steel insole will
often give relief. The treatment of compound fractures of the
metatarsal bones does not differ from that of other bones.
+Dislocations.+ A dislocation is a displacement from each other of the
articular ends of the bones which enter into the formation of a joint.
A diagnosis can usually be made from certain objective and subjective
symptoms, taken in conjunction with an accurate history of the manner
in which the accident occurred.
Examination should be made in a systematic manner in every case, us
follows:
(1) _Inspection._ The limb should be first inspected to note the
position, the alterations of contour, or of the axis of the limb, or
the projection or absence of certain bony prominences. The position is
often so characteristic that a diagnosis can be made by inspection
alone.
(2) _Palpation._ By this one can learn the relation of the displaced
articular ends to each other, unless the swelling is too great, or
the patient is very stout. This method also enables one to ascertain
the absence of normal prominences or the presence of abnormal ones.
The end of the displaced bone may be felt in an abnormal position.
(3) _Measurement._ The limb may only appear to be or is actually
shortened. In the latter event the normal measurements between bony
prominences will be altered.
(4) _A skiagraph_ should be made in all doubtful cases to confirm the
diagnosis of dislocation, and also to ascertain whether there is an
accompanying fracture.
When the patient is stout, or when considerable swelling exists the
use of the X-ray is of especial value.
The attitude of the limb is often so characteristic that simple
inspection will enable one to make a diagnosis by this means alone. In
stout persons, a change in the axis of the limb or a change in
position is apt to be overlooked. The relation of the articular
surfaces can be determined by palpation, unless the swelling is too
great. Measurement of the limb will usually show a shortening,
depending upon the position in which the limb is held. The movements
of a dislocated joint are usually limited. If any movement of the end
of one of the bones is felt, it is always at an abnormal point. Pain
is referred to the dislocated joint and the patient is unable to use
the limb.
+Treatment.+ As a rule, a dislocation should be reduced as soon as the
diagnosis is made, and, if necessary, an anesthetic should be
administered.
When reduction has been accomplished, the bone often goes back with a
snap, the contour of the limb is restored, and the movements of the
joint are free again.
If it is impossible to reduce a recent dislocation, the following
obstacles must be considered: (_a_) interposed portions of the
capsule; (_b_) interposed muscles or tendons or sesamoid bones; (_c_)
torn off fragments of bone; (_d_) a fracture of the shaft close to its
articular end, which would prevent its being used as a lever for
reduction.
The after-treatment of a dislocation is usually quite simple. A
bandage or splint should be applied, which will keep the joint
immobilized for a period of two weeks, after which passive motion and
massage can be begun for fifteen minutes twice daily, the splint or
bandage then to be reapplied for another two weeks.
+DISLOCATIONS AT THE ANKLE JOINT+
+Backward Dislocations+ occur more frequently than those in a forward
direction.
The injury usually is the result of a fall backward while the foot is
flexed. This causes an extreme plantar flexion of the foot. The
astragalus, and with it the foot, is displaced backward. The lateral
ligaments are usually extensively torn. In the majority of cases there
is an accompanying fracture of either one or both malleoli or of the
shaft of the fibula.
+Diagnosis.+ The front portion of the foot is shortened while the heel
is more prominent than normal. The lower end of the tibia protrudes
over the dorsum of the foot and the sharp edge of its articular
surface can be distinctly felt. The extensor tendons and the tendo
Achillis are tense and prominent. It may be distinguished from a
supramalleolar fracture by the fact that the malleoli in the latter
have moved backward with the foot, while in a dislocation backward
they are prominent at some distance in front of the heel.
+Treatment.+ Reduction is usually effected by forced plantar flexion,
the foot being pulled forward and the lower end of the tibia being
pushed backward. These steps are then followed by dorsal flexion of
the foot.
After reduction, the leg should be immobilized for three weeks in a
molded posterior splint. Light passive motion can be begun during the
fourth week. In old unreduced cases an arthrotomy is indicated.
+Forward Dislocations.+ These are much rarer than the backward form.
They are usually due to a forced dorsal flexion of the foot. This form
is less often accompanied by a fracture of the malleoli than is the
case in the backward dislocation. The fibula is seldom broken, the
usual seat of the fracture being in the tip of the internal malleolus
or in the articular surface of the tibia.
+Diagnosis.+ The whole foot appears to be lengthened. The prominence due
to the heel has disappeared; the upper articular surface of the
astragalus can be felt, the tibia and the malleoli being nearer to the
heel.
The condition can be differentiated from a fracture of both bones of
the leg above the malleoli by the fact that in a forward dislocation
the malleoli are further back than normal, while in a supramalleolar
fracture they have moved forward with the foot.
+Treatment.+ Reduction is readily effected by marked dorsal flexion of
the foot, pressure being made in a forward direction upon the lower
end of the tibia, and the foot pushed backward. Plantar flexion now
completes the reduction. The after treatment is the same as in the
backward form.
+Lateral Dislocations.+ The other forms of dislocations seen in the
ankle are those in a lateral direction, either inward or outward. The
diagnosis is usually easy. The upper convex surface of the astragalus
is directed toward the external malleolus and can be felt there. The
inner border of the foot is raised; the outer rests upon the bed.
This form of dislocation is very frequently a compound one, or it is
accompanied by fractures of the bones of the leg or of the astragalus;
but it may occur without these injuries.
+Treatment.+ The treatment of these lateral dislocations differs but
little from that of fractures of the lower end of the tibia and
fibula. Reduction is effected by adduction or abduction of the foot.
The chief danger is from infection on account of the extensive injury
of the skin and soft parts. If reduction is impossible, perform an
arthrotomy.
+Subastragaloid Dislocation.+ Two forms of dislocation can occur in the
joint between the astragalus and the two tarsal bones (os calcis and
scaphoid) with which it articulates. In the true subastragaloid form,
the astragalus continues to articulate with the tibia and fibula, but
it is displaced from its articulation with the os calcis and scaphoid.
In the second form of subastragaloid dislocation, the astragalus is
completely separated from its articulation with the bones of the leg
as well as with the calcaneus and scaphoid. To this form the name
total dislocation of the astragalus is given.
+True Subastragaloid Dislocations.+ These dislocations may occur in four
directions, inward, outward, forward, and backward.
_Dislocation inward._ The most frequent cause is a forcible adduction
of the foot combined with violence acting in the direction of the long
axis of the foot. The diagnosis can be made from the position of the
foot. The foot is adducted and rotated inward, as in a case of
clubfoot. The sole of the foot is directed inward. The inner edge of
the foot is concave and shortened while the outer edge appears
lengthened. The external malleolus and head of the astragalus are very
prominent on the outer side of the foot. Below and behind the inner
malleolus the scaphoid projects beneath the skin.
_Dislocation Outward._ This occurs after forced adduction of the foot.
The symptoms are the opposite of those of the inward variety. The foot
is in the position of a flat foot, its inner edge depressed and outer
edge raised. The inner malleolus is close to the sole of the foot, and
in front of it the head of the astragalus forms a prominence. The
injury is not infrequently compound, so that the astragalus presents
into the wound.
_Dislocation Backward._ The cause is usually a plantar flexion of the
foot. The signs are very pronounced; the head of the astragalus can be
seen and felt lying upon the upper surface of the scaphoid and
cuneiform bones. The anterior portion of the foot is shortened while
the heel is lengthened and the tendo Achillis is very prominent.
_Dislocation Forward._ This follows forced dorsal flexion of the foot,
the patient falling forward after landing with his heels upon the
ground. The diagnosis can be made because of the lengthened anterior
portion of the foot and the shortened heel. An important point in the
diagnosis of subastragaloid dislocation is the absence of any
prominence due to the projection of the body of the astragalus, in
front, behind, or to either side of the malleoli, as is seen in the
case of the tibiotarsal dislocations. A second diagnostic point is the
abnormal position of the calcaneus and scaphoid with relation to the
malleoli and astragalus. The swelling is usually so great that a
diagnosis is very difficult without the use of the X-ray.
+Treatment of Subastragaloid Dislocations.+ Reduction can usually be
effected in recent cases by manipulation and traction. In the inward
variety the existing adduction is at first increased. Pressure is now
made over the outer side of the adduction and the inner side of the
foot, and the foot is then strongly abducted. In the outward variety,
the abduction is first increased. Pressure is then made over the outer
side of the foot until reduction is effected. In the backward variety,
the plantar flexion is first increased and the foot is then strongly
flexed in the opposite direction. In the forward type, forced dorsal
flexion will effect reduction. The foot should be placed upon a
posterior molded splint for three weeks, after which passive motions
are begun. If the reduction is impossible, an arthrotomy with excision
of the astragalus may be necessary.
+Total Dislocation of the Astragalus.+ This form of dislocation is much
more frequent than those of the ankle joint proper, or of the
articulation between the astragalus, calcaneus, and scaphoid. The
displacement of the astragalus may occur in one of six directions:
forward; outward and forward; inward and forward; inward; backward,
and by rotation.
The most frequent variety is the “outward and forward.” In this
variety the foot is rotated markedly inward and the external malleolus
is very prominent. The foot is in a clubfoot position. The dislocated
astragalus can be felt as an irregular angular bone just below the
external malleolus.
+Treatment+ is the same as in subastragaloid dislocations.
+Dislocation of the Metatarsal Bones.+ This may be either complete or
incomplete at Lisfranc’s joint. It occurs most often in an upward
direction. The dorsum of the foot is more convex than normal, while
the sole of the foot is flattened. One can see and feel the displaced
ends (upper) of the metatarsals on the dorsum of the foot. The foot is
shortened and the toes point inward.
Dislocations of the individual metatarsal bones are much rarer. The
middle ones are displaced upward, and the first and fifth, inward and
outward respectively.
+Dislocation of the Toes.+ This occurs most often in the
metatarsophalangeal joint of the great toe after forcible flexion. The
dislocation may be complete or incomplete. In the former case, the
proximal end of the first phalanx and the dorsum of the foot are
prominent, and the head of the metatarsal bone projects on the sole of
the foot. The reduction of toe dislocations presents no difficulties.
+SPRAINS+
+Definition.+ A sprain is a joint wrench due to a sudden twist or
traction, the ligaments being pulled upon or lacerated and the
surrounding parts being more or less damaged.
+Sprains of the Ankle.+ On account of its flexibility and constant use
in weight-bearing, the ankle is the joint most frequently sprained.
Sprains are common in a limb with weak muscles; in a deformed
extremity in which the muscles act in unnatural lines, and in a joint
with relaxed ligaments.
A joint, once sprained, is very liable to a repetition of the damage
from slight force.
+Symptoms.+ The symptoms manifested in a sprain are as follows: severe
pain in the joint; nausea and sometimes syncope; impairment, or loss
of motion; severe pain upon motion; early swelling if hemorrhage is
severe—in any case swelling begins in a few hours; movement of the
joint becomes difficult or impossible; the tear in the ligament may
be distinctly felt; in a day or two pain and tenderness become intense
and discoloration becomes marked.
+Diagnosis.+ Usually the diagnosis is easy to make, but in all doubtful
cases an X-ray picture should be taken in order to be certain that a
fracture does not exist.
+Treatment.+ The first indication is to arrest hemorrhage and to limit
inflammation. For the first few hours apply pressure and an ice-bag.
Wrap the joint in absorbent cotton, wet with iced water; apply a wet
gauze bandage, and put on an ice bag.
In a mild sprain, use lead and opium wash. In a severe sprain, place
the extremity upon a splint and apply to the joint flannel kept wet
with lead-water and laudanum, iced water, tincture of arnica or
alcohol and water. If the pain is severe, a small dose of morphine
should be given.
Judicious bandaging limits the swelling. When the acute symptoms begin
to subside, rub stimulating liniments, such as chloroform or arnica,
upon the joint once or twice a day and employ firm compression by
means of a bandage of flannel or rubber. Later in the case use hot and
cold douches, massage, passive motion and the bandage.
Another method of treatment of sprains of the ankle is by strapping
with adhesive plaster, but it is advisable only for slight injuries.
In severe cases, in which extensive laceration of the ligaments is
suspected from the marked extravasation, it is best to immobilize the
foot in a plaster-of-Paris splint for two weeks; later baking in a
hot-air oven (see “Arterial Hyperemia”) with massage, and active and
passive motion are advisable.
In simple sprains, the fixation does not produce serious stiffness,
and without fixation the repair of the ligaments is only partial. In
the latter case, the result is weakness of the ligaments and an
instability of the foot which leads to frequent recurrence. This
explains many habitual sprains. On the other hand, under appropriate
treatment, a sprain should recover without leaving any functional
disturbance.