Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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separated and the muscles lose their control over the joint ; second,
these ligaments may not only yield, but a fragment of one of the car-
tilages may become actually broken oflF from the main portion ; third,
the femur may perhaps escape behind some portion of an interarticular
cartilage, and thus, instead of the cartilage placing itself between the
joint surfaces, the femur itself may have thrust it into this position;
fourth, a cartilage or some portion of a cartilage may become hyper-
trophied, and thus give rise to the symptoms described ; fifth, in other
cases still, a bony, cartilaginous, fibrinous, or calcareous growth or
concretion forming within the joint, and, if originally attached, becom-
ing separated from the capsule, may move about more or less freely,
and give rise to the same class of symptoms which we have described.

This last variety has generally been described under the name of
''floating cartilages;" but since these bodies are not always cartilagi-
nous, and especially since they do not always by any means move so
freely as to be properly designated as ** fioating," the term is less
appropriate than that originally given by Hey, and which we have
chosen to adopt.

Treatment. — For the purpose of obtaining immediate relief, it is gen-
erally sufficient to fiex the leg completely and then suddenly extend
it, or to combine this motion with a slight twisting or rocking of the
knee-joint. Sometimes this experiment has to be repeated several
tiroes before it is completely successful, and in a few instances it has
failed altogether. I think I must have met with ten or twelve ex-
amples in the course of my practice, and in no instance has the sudden
flexion and extension of the limb failed to overcome the difficulty.

As to the question of subsequent treatment, especially as to whether
it is proper to attempt their extirpation when they are found to be
loose, or to make any other surgical interference, I prefer to leave its
consideration to those general treatises upon surgery where it more
properly belongs.



CHAPTER XIX.

DISLOCATIONS OF THE LOWER END OP THE TIBIA.

%n.— ** Tibio-tareal luxations ;" Malgaigne. " Dislocations of the ankle-joint ;"
Chelius and others.

The tibia may be dislocated at its lower end in' four directions;
namely, inwards, outwards, forwards, and backwards. Most of these
dislocations complicate themselves with fractures of the fibula or of
the tibik, or with fractures of both bones.

Dupuytren, Malgaigne, and a few other surgeons have reported ex-
amples also of dislocations forwards and inwards.

Boyer, with a majority of the French writers, and several English
46



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714 PISLOCATIONS OF LOWER END OF THE TIBIA.

and German surgeons, speak of these dislocations as belonging to the
foot ; consequently the outward dislocation of Boyer is the inward
dislocation of Sir Astley Cooper, Malgaigne, myself, and others, who
prefer to regard the tibia as the bone dislocated.

§ 1. Dislocations of the Loweb End of the Tibia Inwabds.

8yn, — '' Inward tibio-tarsal luxations ;" Malgaigne. ^* Dislocations of the fixrt
outwards;** Bojer and others.

Causes. — This dislocation is occasioned generally by a fall from a
height, upon the bottom of the foot, the foot receiving at the same
moment a suificient inclination outwards to determine the main force
of the impulse towards the inner side of the ankle. It may be pro-
duced also by a blow received directly upon the outside of the leg
just above the ankle, or by a violent twist or wrench of the foot out-
wards.

Pathological Anatomy. — I have already, in the chapter on fractures
of the fibula, stated my opinion that a large majority of those acci-
dents which have been called inward and outward dislocations of the
tibia, were merely examples of lateral rotation of the astragalus within
the half ginglimoid and half orbicular socket formed by the lower
extremities of the tibia and fibula ; and that true dislocations, either
partial or complete, are at this joint and in these directions very rare
occurrences. We shall continue, however, in accordance with the
general practice of writers, to call them all dislocations, whether the
astragalus simply rotates on its axis, or is displaced laterally and hori-
zontally from the tibia.

In the most common form of the accident, then, when the foot is
violently twisted outwards, the astragalus becomes tilted upon its outer

and upper margin in such a
Fig. 812. way as that this margin slides

inwards and places itself under-
neath the middle portion of the
lower articulating surfaceof the
tibia ; its upper and inner mar-
gin descends toward the ex-
tremity of the malleolus inter-




nus, and the outer face of the
astragalus presents obliquely
upwards and outwards, instead
of directly outwards as it would
do in its natural position. This
cannot occur without a rupture

Dislocation of the lower end of tbe tibia inwards. of the internal tibio-tarsal liga-

ments, or a fracture of the mal-
leolus internus, or both ; indeed, a fracture of the internal malleolus is
a very common circumstance in connection with this form of disloca-
tion. Much more frequently, however, the fibula itself gives way at
a point within from two to five inches of its lower extremity; or
sometimes the fracture in the fibula occurs through that portion which



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DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 715

forms the malleolus externus. For more particular information as to
the causes and relative frequency of these fractures, I refer the reader
Xo the chapter on fractures of the fibula.

Rarely it happens that, instead of this lateral rotation of the astra-
galus, there occurs a true lateral displacement of the tibia inwards
upon the astragalus, and the outer portion of the lower articulating
surface of the tibia comes to rest upon the inner portion of the upper
articulating surface of the astragalus ; or it may slide completely off
in the same direction ; a result which is usually attended with a lacera-
tion of the muscles and integuments, converting the accident into a
compound dislocation. In some cases this extreme displacement occurs
without such lacerations.

Fig. 313.




Dislocation of the lower end of the tibia inwards.

In this form of the accident, the true lateral luxation, the fibula may
remain unbroken and undisturbed, the tibia merely having become
displaced inwards ; or the fibula may give way also above the articula-
tion, while the malleolus internus, and the internal lateral ligaments
are equally liable to rupture as in the other form of the accident.

Sometimes, in addition to these complications, the lower end of the
tibia is found to be broken obliquely upwards and outwards from the
articulating surface, leaving that fragment attached to the fibula which
corresponds to the inferior peroneo- tibial articulation.

Symptoms, — The foot is more or less violently abducted, the sole of
the foot presenting downwards and outwards instead of directly down-
wards ; the malleolus internus projects strongly at the inner side of



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716 DISLOCATIONS OF LOWEB END OP THE TIBIA.

the joint; and at the outer side there is a correspoDding depreasioD,
generally most marked a little above the articulation near the point
of fracture in the fibula. The pain is very great, and the foot is
immovably fixed so far las the volition of the patient can determine
motion, but the surgeon can generally move it pretty freely, yet not
without causing a great increase of the pain. When the dislocation
is complete, and the fibula also is broken, the limb becomes slightly
shortened.

Treatment. — When the accident is of the nature of a simple rotation
of the astragalus upon its axis, the reduction is often accomplished
with the greatest ease by seizing upon the foot and forcibly adducting
it. Not unfrequently the patient himself, or some other person who
is present, has effected the reduction before the surgeon is called. In
other cases, and especially when it partakes of the nature of a true
dislocation, much difficulty is sometimes experienced in the redaction.
The surgeon ought then to flex the leg upon the thigh, in order to
relax the gastrocnemii muscles, and holding the foot midway be-
tween flexion and extension, he should pull steadily upon it with his

Fig. 814.



own hands, while an assistant makes counter-extension and supports
the limb with his hands, grasping the thigh above the knee. At the
same moment lateral pressure should be made upon the projecting
bone in the direction of the articulation. It is of some use, also, to
occasionally flex and extend the limb moderately, and to give to the
foot a gentle rocking motion. If more force is needed, it may be ap-
plied by placing the limb over a firm double-inclined fracture-splint,
and making the extension by the aid of a screw attached to the foot-
board, as we have suggested in certain cases of dislocation at the knee.
Or we may employ the pulleys after the manner represented iu the
accompanying drawing.

Charles Sauer, aged about thirty years, while carrying a weight
upon his shoulders, on the 6th of May, 1854, slipped upon the side-
walk, and fell, dislocating the left tibia inwards, and fracturing the
fibula four inches from its lower end. I was in attendance soon after



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DISLOCATIOXS OF LOWEB END OF TIBIA INWARDS. 7i7

the accident occurred, and found the tibia projecting inwards, with
the other symptoms usually accompanying a simple rotation of the
astragalus upon its axis. Seizing the foot with my hands, and flex-
ing the leg, while an assistant held up the thigh and made counter-
extension, I had scarcely begun to pull upon the foot before the re-
duction was effected. Dupuytren's splint was at once applied, and
the subsequent inflammation was so trivial as scarcely to deserve
notice. In six weeks the limb was sound, and free from all anchy-
losis.

In my report on dislocations, made to the New York State Medical
Society for the year 1856, 1 have mentioned twelve similar examples,
in addition to some examples of compound dislocations, all of which
were easily reduced, but the results were not always so favorable.

If, as rarely happens, the tibia is broken obliquely into the joint,
the complete reduction of the dislocated tibia may be found impos-
sible, owing to the obstacle presented by the displaced fragment.

The following I am disposed to regard as examples of dislocation
accompanied with fracture of the tibia within the articulation: —

Brockway, of Cortland, N. Y., aged about twenty-seven years, con-
sulted me at my of&ce, a few years since, in relation to the condition of
his foot. I found the tibia dislocated inwards, and projecting more
than an inch beyond the astragal as; the sole was turned outwards,
compelling him to walk upon the inside of his foot ; the fibula was
bent inwards against the tibia, at a point about four inches above the
ankle, which seemed to have been the seat of fracture of this bone.
He stated to me that immediately after the receipt of the injury,
which was occasioned by a fall from a height upon the bottom of his
foot, he had consulted a surgeon, .Dr. A. B. Shipman, of Cortland,
and that although Dr. Shipman made repeated and violent efibrts to
effect the reduction, he had been unable to do so. Indeed, the bone
had never been removed from the position in which it was at first
placed.

J. Borland, of Erie Co., N. Y., set. 81, fell under a rolling log, and
dislocated his left tibia inwards, breaking off the internal malleolus,
and fracturing the fibula four inches from its lower end. Dr. Sweet-
land, an old and experienced practitioner, was immediately called, who,
with another surgeon, failed, after repeated efforts, to reduce the
dislocation. I saw the patient, in consultation with these gentlemen,
twenty-four hours after the accident. The foot and ankle were some-
what swollen, and discolored. The lower end of the tibia projected
so far inwards as to threaten a rupture of the skin ; the foot was
strongly everted. We first flexed the leg upon the thigh, and made
extension with our hands, in the manner I have already directed.
This we continued several minutes; finally moving the limb in various
directions, and adding forcible pressure upon the inside of the pro-
jecting tibia. We then placed the leg over a double-inclined plane,
and, securing it firmly in place, we attached a screw to the f^t through a
sandal and gaiter, and while the leg was well fiexed upon the thigh, we
renewed the extension and lateral pressure. This was continued, with
the application of more or less power, during half an hour, meanwhile



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718 DISLOCATIONS OF LOWER END OF THE TIBIA.

cbangiog the position of the limb oocasionally by varying the angle
of the splint. Our efforts were prolonged in all more than one hoar,
when, as we had made no impression upon the bone, and the patient had
repeatedly implored us to desist, the attempt was given over. The
end of the tibia seemed to rest partly upon the astragalus, and the
extension was plainly all that was demanded, but the obstacle was
beyond doubt within the articulation, or rather between the tibia and
fibula.

Four weeks after the accident, Mr. Borland walked on crutch^
and during a year he was compelled to use a cane, but since that time,
a period of twelve years, he has walked without any artificial support.
For a year or two he felt a yielding in his ankle, as the weight of his
body settled upon his limb ; but this gradually ceased, and for some
years past he has walked without any halt, and seems to step as firmly
as before the accident. The foot still inclines outwards ; the tibia
projects inwards one inch, and the broken ends of the fibula can be
felt resting against the tibia, where they are reunited. .

Not long since, I had occasion to amputate a limb for a compound
dislocation inwards at the ankle-joint, and the possibility of this frac-
ture was confirmed by the dissection. About one-third of the outer
portion of the articular surface was broken off obliquely, and the
fragment was lying so displaced that a reduction would have been
rendered impossible.

Dr. Townsend, of Boston, has reported a case of compound dislo-
cation, in which also amputation became necessary ; and, with other
injuries, the dissection showed a fragment from the outer margin of
the tibia, one inch and a half long, and one inch thick at its widest
part^ with a very sharp point, dbplaced, and lying almost transyersely
oyer the astragalus.'

For a more full account of the prognosis and the general manage-
ment of these cases subsequent to the reduction, I beg again to refer
the reader to the chapter on fractures of the fibula ; and for my yiews
in relation to the treatment of compound dislocations of the ankle-joiDt,
I will refer also to the chapter on compound dislocations of the long
bones.

§ 2. Dislocations of the Lower End of the Tibia Outwards.

i^A.—*' Outward tibio-tarsal luxation;'^ Malgaigne. '^Dislocationsof thefoot
inwards," of others.

The causes are the same or similar to those which are known gen-
erally to produce dislocations inwards ; only that the force of the
concussion or the direction of the rotation must have been reversed.

The external lateral ligaments, peroneo-tarsal, are either ruptured,
or the lower portion of the fibula gives way, or both of these circum-
stances may have happened ; while the internal malleolus may also
yield to the shock and to the weight of the body now resting upon it.

1 Townsend, Mass. Hosp. Reports, Boston Med. and Surg. Joum., yol. xxxiii.
p. 277.



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OF LOWER END OF TIBIA OUTWARDS. 719

The nature of the accident may Fig. 815.

vary also in respect to the rela-
tive position of the articular sur-
faces; the astragalus may simply
rotate on its inner and upper
margin, or the tibia, with the
fibula of course, may actually
slide outwards until the lower
end of the tibia more or less
completely abandons the upper
surface of the astragalus.

The modes of reduction, and
the general principles of treat-
ment subsequently, will not
differ from those which we have
mentioned as suit£^ble for dis-
locations in the opposite direc-
tion. The examples which have
fallen under my observation are
not numerous, but the reduction
has always been easily effected.
Thus, a man, sBt. 21, fell from a
scaffolding, alighting upon his
feet. He says that his left foot
struck the ground obliquely
and upon its outer margin. I
found the fibula projecting very
strongly outwards, evidently

carrying with it the tibia; the Duiocatioikof the lower end of the tibuomwardt.
malleolus internus was broken

off, and the foot forcibly turned inwards. Without either flexing the
leg upon the thigh or calling to my aid any degree of counter-exten-
sion except what was made by the weight of the body, I grasped the
foot and grew upon it gently, while at the same moment I rotated the
foot outwards. Immediately the bones resumed their places.

In June of 1846, Henry Wilson, ast. 38, consulted me in relation to
his foot, which he said had been dislocated four weeks before. He
had fallen upon the outside of his foot and turned it suddenly inwards,
* so that when he looked at it he found the sole presenting toward the
opposite side. Seizing upon it with both hands, he pressed it forcibly
outwards, and the reduction immediately took place with a snap.
Yery little soreness followed, nor was he confined to his house a single
day. He had continued to walk about with only a slight halt in bis
gait, nor would he have thought it necessary to consult me at all ex-
cept that the tenderness had not yet disappeared. He was not aware
that the fibula had been broken also, until I called his attention to the
fact. The fracture had taken place two inches above the ankle ; and
although it was already united, the depression occasioned by its having .
fallen in somewhat toward the tibia was very plainly felt and recog-
nized.



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720 DISLOCATIONS OP LOWER END OP THE TIBIA.



§ 8. DiSLOOATIONS OF THE LoWKR EnD OF THE TiBIA FORWARDS.

8yn. — ^* Forward tibio-tJLrsal luxations;*' Malgaigne. '^DislocadonB of the foot
backwards,*' of others.

Causes, — This dislocation may be produced by a violent extension
of the foot upon the leg ; as, for example, when, the foot being en-
gaged under a piece of timber, the body falls backwards to the ground:
or when, the leg remaining fixed, a heavy weight descends upon the
foot, the foot resting upon an inclined plane; by a blow upon the
front of the foot; or it may be caused by a fall upon the bottom or
back of the tibia, or possibly even by the toes being brought violently
in contact with some firm body. No doubt it may be caused also by
any of that class of accidents which are known to produce fractures
of the fibula with fracture of the malleolus internus, or fracture of the
fibula with rupture of the internal lateral ligament ; for example, bj
a fall upon the bottom of the foot, or upon the* inside of the sole,
followed immediately by an outward twist of the foot. In these cas^
the luxation of the foot backwards, or, as it is generally found to be,
the semi-luxation, may be consecutive upon the accident^ and the
result only of the contraction of the gastrocnemii. It may, therefore,
occur immediately afler the fracture has taken place, or not until
after the lapse of several days.

Pathological Anatomy. — The displacement may be very slight, so
that the end of the tibia is only a little advanced upon the astragalus;
or it may be such that the tibia rests one-half upon the naviculare
and one-half upon the astragalus, or it mny even desert the astragalas
entirely. The fibula may at the same time be broken at any point
but it is generally broken two or three inches above its lower ex-
tremity. The malleolus internus is also sometimes broken, but more
often the internal lateral ligament is torn. Still more rarely a fracture
occurs through the posterior margin of the articular surface of the
tibia.

Symptoms, — The length of the foot in front of the tibia is dimin-
ished, while the projection of the heel is correspondingly increased;
the toes are turned downwards and the heel drawn upwards, and fixed
in this position; the end of the tibia may generally be distinctly felt
in front of the astragalus; the extensor tendons of the toes are sharply
defined, while the tendo-Achillis is curved forwards, and tense.

At the regular meeting of the New York Pathological Society,
Nov. 22, 1865, 1 present^ a specimen obtained from the dissecting-
room of the Bellevue Hospital College. The history of the case was
unknown.

Before dissection, the foot was observed to be turned outwards, and
shortened in front of the tibia, while there was a corresponding length-
ening of the heel. The specimen, after dissection, disclosed a fracture
of the internal malleolus half an inch above its lower end, and a frac-
ture of the fibula a little above its lower end. The tibia was displaced
forwards about three-quarters of an inch, so that only the posterior
half of its lower end rested upon the articular surface of the astragalus,
and at the point of contact with the astragalus a new socket was



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OF LOWEB END OF TIBIA FOBWABDS. 721

formed in the tibia, concave upwards, half an inch deep, and pre-
senting an appearance as if the posterior lip of the lower end of the
tibia had been broken oflF and had become displaced upwards. It was
supported by a broad buttress of bone. It is not certain, however,

Fig. 816. Fig. 817.




Partial ditloeatlon of the tibia forwards, Partial dislocation of the tibia forwards, with

with fraetares of malleoloa internos, and fracture of the malleolas internos, and flbola.

flbala. Skeleton.

but that this appearance was occasioned solely by the long-continued
pressure of the tibia upon the astragalus at this point. The fragments
of the malleolus internus, and the lower fragment of the fibula, re-
mained attached to their upper fragments and to the two sides of the
astragalus in their normal positions, consequently each fragment was
inclined downwards and backwards at an angle of 45°. The lower
fragment of the fibula was driven upwards, also, but both of the frac-
tures were firmly united. This specimen is now in the museum of
the Bellevue Hospital College.

At the same meeting of the Pathological Society I reported the case
of Mary Conlan, set. 38, admitted to Bellevue Hospital, Nov. 18th,
1865, having been thrown three days before from a street car. She
could give no account of the manner in which she fell. I saw her
Nov. 16th. The limb was then much swollen, and I diagnosticated a
fracture of the lower end of the fibula. (It had been supposed to be
a mere sprain up to this time.) The limb was directed to be wet with
cool water, and to rest upon a pillow. From this time I looked at it
occasionally, to see whether the swelling had sufficiently subsided to
warrant the application of a splint. Nov. 20th it was examined again
carefully by the house surgeon. Dr. Farrall, but no displacement was
noticed. Nov. 28d I found the lower end of the tibia displaced for-
wards, and ascertained, also, that the internal malleolus was broken at
its base. The dorsum of the foot, measuring from the front of the
tibia to the end of the great toe, was shortened half an inch. The
heel was lengthened.

There can be no doubt but in this case the dislocation occurred sub-
sequent to the fracture, and that it was caused by the contraction of
the gastrocnemii. I reduced the dislocation a day or two later, and



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722 DISLOCATIONS OP LOWER END OP THE TIBIii.

maintained it in position by the method which I shall presently de-
scribe.

Dr. Yoss reported to the Society a similar case which had come
under his notice, and Dr. Back remarked that he also had met with
such examples.'

Dr. Prince, of Illinois, has reported a case of this character, which,
remaining displaced, led to a prosecution for damages. A lady, sl
40, ipet with an accident, Aug. 81, 1863, which resulted in a fracture
of the fibula near its lower end, and a partial dislocation of the tibia
forwards to the extent of one inch. The toes were not pointed down-
wards, but the foot had its natural angle with the leg. Nearly three
months after the accident. Dr. Prince, assisted by two other surgeons^
broke up the adhesions^ and reduced the bones to their natural posi-



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 83 of 100)