Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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Treatment. — ^The reduction is to be attempted by flexing the leg
upon the thigh, and making extension from the foot^ wHlIe, at the
same moment^ pressure is made upon the front of the tibia and against
the heel. When the bone begins to slide into place, the foot should
be forcibly fiexed upoi^ the leg. A slight lateral motion or rotation
in either direction may assist in restoring the bones to place.

In general, the dislocation has been easily reduced, but in a ma-
jority of the examples recorded great difficulty has been experienced
in maintaining the reduction ; and in a few cases it has been found
impossible to do so.

In order to maintain the reduction, the leg, flexed upon the thigh,
should be laid on its back in a box; and the foot supported firmly
against a foot-piece placed at a right angle with the box. In this
position, the weight of the leg will tend somewhat to overcome the
action of the muscles which are disposed to displace the foot back-
wards. Generally it will be found necessary to make additional pres-
sure directly upon the front of the leg above the ankle ; which, in
order that it may not prove mischievous, must be effected with some
soft material, and must be applied over a broad surface. Perhaps
nothing will better answer these indications than to pass a cotton band,
six or eight inches in width, through slits or mortises in the sides of
the box ; these slits being of a width equal to the width of the band,
and placed at a point sufficiently below the level of the supine of the
tibia, so that when the band is made fast underneath the box, it shall
press the leg firmly backwards. To prevent the heel from suffering
in consequence of this pressure, it also should be supported, or sus-
pended by another band passing underneath the heel and fastened
above to the top of the foot-board, The plaster-of-Paris dressing, also,
answers the purpose exceedingly well in these cases.

Dupuytren relates the following example of this accident : —

Pierre Froment, aet. 38, was carrying a heavy weight upon his back
and had his right foot in advance, when by accident he came suddenly

> New York Joum. Med., April, 1866, p. 40.

s Cincinnati Joum. Med., April, 1867, p. 203. See also Todd*s Cyclopedia of
Anat. and Phys. ; Adams on Ankle-Joint, p. 160 et seq.

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in contact with a beam placed across his path. Under the fear of
being precipitated forwards, he made a sudden effort to throw his body
backwards, by which he lost his balance, and fell with the point of
the left foot inclined inwards and forwards, and his whole weight was
thrown first on the outer side, and then on the front of the ankle-

On examination, the leg seemed to be planted upon the middle of
the foot ; the toes were directed downwards and the heel drawn up.
On the instep there was a large bony prominence, over which the ex-
tensor tendons of the toes were stretched like tense cords. Behind the
joint was a deep hollow, at the bottom of which the tendo-Achillis
could be felt forming a tense, resisting, semicircular cord, with its con-
(savity directed backwards. The fibula was also broken ; the lower
end of the lower fragment remaining attached to the foot, while the
upper end of the same fragment was carried forwards by the displace*
ment of the tibia, so that it lay nearly horizontally, with its broken
extremity directed forwards.

Dupuytren directed one assistant to fix the leg, and a second to
make extension from the foot^ while Dupuytren himself, standing on
the outer side of the limb, forced the heel forwards and the tibia back-
wards. The first attempt succeeded partially, and the second com-
pleted the reduction. The limb was then placed in the apparatus
employed by this surgeon for a fractured fibula, which we have before
described, and laid on its outer side in a semiflexed position. The
patient recovered rapidly, and in little more than a month he was able
to walk.^

But such fortunate results have not usually been observed ; indeed,
Dupuytren encountered much more serious difficulties in two other
cases which came under his own notice, one of which he has himself
recorded. This was in the person of a woman set. 48, who was brought
to the H6tel Dieu in 1815, the accident having just happened from a
slip in going down stairs. The fibula was broken, and also a frag-
ment was broken from the tibia. The house surgeon reduced the
bones, and placed the limb in the ordinary apparatus for broken legs;
but on the following day Dupuytren found them reluxated, and laid
the limb on his own splint, but the pressure requisite to keep the tibia
in place soon induced sloughing, ulceration, and abscesses, and after
four months' treatment, during which time the tibia had been repeat-
edly displaced, she left the hospital, able to use her limb, but with a
certain amount of incurable deformity.'

Malgaigne mentions the third example as having been seen by
himself in Dupuy tren's service in 1832, in which case the attempt to
maintain the reduction by a tourniquet resulted in gangrene and
finally the death of the patient.' Earle lost a patient after amputation
made on the eighth day. The tibia could not be kept in place, and
the amputation became necessary on account of the final protrusion
of the bone through the integuments, which had sloughed.^

1 Dupuytren, Injuries and Dis. of Bones, London ed., p. 278.
• Op. cit., p. 276. s Malgaigne, op. cit., p. 1044.

« Malgaigne, op. cit., p. 1044.

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§ 4. D1BLOCATION8 OF TBE Lower End of the Tibia Backwards.

8yn,—'' Backward tibio-tanal lazatioiiB ;" Malgaigne. '' DUlocatioiiB of the foot
forwards," of others.

More rare than the dislocations forwards, Malgaigne has, neverthe-
less, succeeded in collecting five examples.

They appear to have been produced, generally, by a cause the re-
verse of that which we have seen to produce in certain cases the pre-
ceding dislocation. Thus, while the dislocation forwards is produced
sometimes when the foot is in violent extension, this dislocation has
occurred, in at least two *or three cases, when the foot was forcibly
flexed upon the leg.

The symptoms are strongly marked and characteristic. The length
of the foot from the tibia to the ends of the toes is increased one inch
or more ; the heel being correspondingly shortened, or rather wholly
obliterated; a portion of the articulating surface of the astragalus
may be distinctly felt in front of the tibia; the posterior surface of
the tibia touches the tendo- Achillis ; the leg is shortened, and the mal-
leoli approach the sole of the foot.

In most cases one or both of the malleoli have been broken ; and
R. W. Smith, who has reported one of the examples alluded t*o, be-
lieves that the dislocation is never complete.

Pig. 81S.

Fig. 319.

Dltlocations of the lover «ad of the UbU backwards.

Reduction should be attempted by a method similar to that which
has been recommended in all the other dislocations of the ankle; only
with such modifications as the peculiarities of the case must neces-
sarily suggest.

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Syn, — *' Luxations of the superior peroneo-tibial articulation;'^ Malgaigne.

Surgeons have frequently described a condition of the peroneo-
tibial articulation in which the ligaments have become relaxed, giving
a preternatural mobility to the head of the bone. It is also not unfre-
quently displaced upwards, in consequence of an oblique fracture of
the tibia. I have myself seen several examples of both these acci-
dents; but simple traumatic dislocations, which can only occur for-
wards or backwards, are very rare.

§ 1. Dislocations of the Upper End of the Fibula Forwards.

Msilgaigne has collected three examples of this luxation, uncom-
plicated with any other accident, and not, apparently, due to any ab-
normal condition of the ligaments, two of which, at least, seemed to
have been produced by the violent action of the muscles which are
attached to the anterior face of the fibula. The third example, re-
ported by Thompson in the London Lancet,^ permits a doubt as to
whether the displacement was occasioned by muscular action, or by
a direct blow upon the part.

The signs which characterize the anterior luxation are the absence
of the head of the fibula in its natural position, and its presence in
front, near the ligamentum patellse; the altered direction of the biceps
flexor cruris muscle ; and, in one case, considerable deformity in the
shape and position of the leg has been observed.

Thompson and Jobard were unable to accomplish the reduction
while the leg was extended upon the thigh, but succeeded readily
after having flexed the leg. On the other hand, Savournin succeeded
with the leg extended, but with the foot flexed upon the leg. Mal-
gaigne, to whom I am indebted for these observations, thinks that
flexion of the leg, combined with flexion of the foot, wouldj render
the reduction more oasy.

In whatever position the limb is placed, the surgeon must rely
chiefly upon forcible pressure made with the fingers against the front
and upper portion of the displaced bone.

J. E. Hawley, of Ithaca, N. Y., late Prof, of Surgery in the Geneva
Medical College, has furnished me with a brief account of a case
which came under his own observation.

On the 29th of March, 1854, Bambak, while vaulting upon the

> Op. cit., 1860, yoL i. p. 885

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parallel bars in a gymnasium, unintentionally made a complete somer-
set, and fell with his right foot upon the edge of ^ plank. Dr. Hawley,
who was immediately called, found his right leg semi-flexed and im-
movably fixed. The head of the fibula was plainly felt in front of
its natural position, near the ligamentum patellae. The patient was
suffering the most intense pain. Extension and counter-extension
were made, and while the doctor was pressing with both of his thnmbs
upon the head of the fibula, it went into its place with an andible
snap. The relief was instantaneous. Complete rest was obserred
for a few days, while cooling lotions were constantly applied, and
within a week he was able to attend to his usual duties.

§ 2. Dislocations of thb Upper End of the Fibula Backwaiii>&

Sanson has recorded one example, in which the passage of the
wheel of a carriage across the upper part of the leg, precisely on a
level with the peroneo-tibial articulation, ruptured the ligaments which
bind the fibula to the tibia, and caused a displacement^ which, however,
seems to have been spontaneously overcome. Nevertheless, there re-
mained a preternatural mobility, permitting the fibula to be pushed
easily backwards or forwards upon the tibia.

I have found only two other cases of backward dislocation, one of
which is related by Dubreuil. A man, sdL 62, in order to save him-
self from falling, sprang suddenly, with his right leg in a position of
extreme abduction, and at the same moment he experienced a severe
pain in the region of the peroneo-tibial articulation. The head of the
fibula was found to be thrown backwards, and formed under the skin
a marked prominence ; the foot was drawn outwards, and the whole
outside of the limb became cold and numb. Dubreuil flexed the leg
moderately, and pressing the head of the fibula from behind forwards,
the reduction was easily effected. On the following day, the limb
having been straightened, the dislocation was found to be reproduced.
It was again replaced, and the knee covered with a leather cap, secured
moderately tight. After twelve days of complete rest» the knee was
moved gently, and on the seventeenth day the patient walked with
the help of a cane. For some time the leg had a tendency to incline
outwards ; but in about three months the cure was perfectly estab-

It is probable that in this case the dislocation resulted from the
violent action of the biceps flexor cruris. Such, at least, is the opinion
of both Dubreuil and Malgaigne, and I see no reason to question the
correctness of their theory.

The other example has been reported by Dr. Jos. G. Richardson,
resident physician to the Pennsylvania Hospital. John Dixon, set. 9,
fell five feet and struck upon the outside of xhe left knee. When ad-
mitted to the hospital, the leg was partially flexed and the toes a little
everted, and he was unable to flex or to extend the limb completely.
The head of the fibula was seen three-quarters of an inch behind its

1 Malgaigne, op. cit, torn. ii. p. 886.

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natural positioD, and the biceps was felt distinctly attached. There
'^as no Other lesion. The reduction was easily accomplished by press-
ing with the fingers upon the inner and back part of the fibula,
t;l)rusting it outwards and forwards. A compress and bandage were
applied, and the limb placed at rest. The reduction continued com-
plete, and after a few days he was permitted to use the limb.^



Nelaton relates the only example of a simple luxation of this
articulation of which we have any information. The patient who was
the subject of this accident presented himself at the hospital under the
care of M. Gerdy on the thirty-ninth day after the accident, which had
been occasioned by the passage of the wheel of a carriage obliquely
across the leg in such a manner as to push the malleolus externus
directly backwards. The lower end of the fibula was in almost direct
contact with the outer margin of the tendo-Achillis ; the outer face of
the astragalus, abandoned by the fibula, could be distinctly felt in
nearly its whole extent ; the foot preserved its natural position ; and
he could walk pretty well, only that he was obliged to step with some
care. M. Gerdy believed that the bone was too firmly fixed in its new
position to be moved, and therefore made no attempt at reduction.



§ 1. Dislocations or th£ Astragalus.

Malgaigne, who speaks also of luxations " sub-astragaloid," has
thought proper to call the dislocations which we now propose to
consider, "double dislocations of the astragalus." In the variety first
named, the astragalus retains its connections with the tibia, but sepa-
rates from the scaphoid bone, while its relations to the calcaneum are
only slightly disturbed. This we prefer to regard as one of the many
varieties of tarsal luxations, and shall appropriate to it no specific
appellation, except to designate it as astragalo-scaphoid or astragalo-
calcaneo-scaphoid, according as more or less of the several articula-
tions are disturbed.

I Richardson, Amer. Jotun. Med. Sd., April, 1868.

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In the second named variety, called by Malgaigne a " double" loxa
tion, and which constitutes the subject of this chapter, the asU-aga-
lus abandons all the articular surfaces against which it is natarallj
applied, and thrusts itself out from between the tibia, fibula, cal-
eaneum, and scaphoides ; so that it may be said to have suffered a
triple or quadruple rather than a " double" dislocation, as is implied
by the nomenclature adopted by Malgaigne. This we choose to regard
as the only true dislocation of the astragalus, and as such we propose
to designate it by the simple term " dislocation of the astragalus,"

The astragalus may be dislocated forwards, outwards, inwards, back-
wards ; or it may be dislocated obliquely in either of the diagonals
between these lines; it may be simply rotated upon its lateral axis,
without much, if any, lateral displacement; and, finally, it has been

occasionally driven be-
Fig. 830. tween the tibia and fibu-

la, tearing away the in-
termediate ligaments, and
generally fracturing one
or both bones of the 1^.
Causes. — ^The causes
which have been found
chiefly operative in the
production of this dislo-
cation are very much the
same as those which pro-
duce, under other circnm-

Dislocation of astragal as outwards. Anatomical relationi. StaUCCS, a dislocatloU of

the lower end of the tibia.
Thus, a fall from a height upon the bottom of the foot, accompanied
with a violent abduction, adduction, flexion, or extension, may deter-
mine a dislocation of the astragalus inwards, outwards, backwards, or
forwards. Sometimes it is accomplished by a mere wrenching and
twisting of the foot in machinery, or in the wheel of a carriage, or by
being caught between two irregular bodies. It may be produced also
by a direct blow.

Symptoms, — The great prominence occasioned by the displacement
of the bone in either of these several directions, accompanied gene-
rally with more or less lateral deviation of the foot, is alone sufficient
to indicate the true nature of the accident. In some cases, also, the
foot is forcibly flexed or extended ; the leg is shortened in conse-
quence of the tibia having fallen down upon the calcaneum ; the super-
incumbent skia and tendons are rendered tense; blood is effused, and
swelling speedily occurs. In the backward dislocation, the position
of the foot is not much changed, but the tibia being slightly carried
forwards, the length of the dorsal aspect of the foot is proportionably

Such are the symptoms which plainly enough indicate the dislo-
cation in the most simple cases; but in a majority of the examples
which have been seen, the integuments have been more or less exten-

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sively torn, exposing to the eye at once the naked bone, and thus
removing all chance of error in the diagnosis. '

Norris mentions a case, seen by Hammersley, in which the astra-
galus was thrown completely out, and was subsequently found in the
earth where the patient had received his injury. Inflammation, gan-
grene, and tetanus supervened, and the patient died on the seventh


Fig. 821.

Fig. 822.

Simple dlsloe&tions of the Mtragalas outwards.

Compound dislocation of the astragalus inwards.

Prognosis. — It will be readily,understood that nothing short of very
great violence could disturb and completely break up the connections
of a bone so compactly and firmly seated as is the astragalus, and
that, aside of any unusual complications, under the most favorable
circumstances, intense inflammation must naturally be anticipated;
and, with few exceptions, this has actually taken place. Even when
reduction has been promptly and easily effected, inflammation, gan-
grene, and death have sometimes speedily ensued. But more often the
reduction has been found to be exceedingly diflScult or impossible, and
complete removal of the bone or amputation has been immediately

In a limited number of cases, on the other hand, the bone has been
easily reduced, and recovery has taken place, with a tolerably useful
limb; or resection has been practised with an equally favorable result;
in still other cases the bone has been left protruding, and the patient
has finally recovered so far as to be able to walk again, but in such
a crippled condition as to render the achievement a very doubtful
triumph of conservative surgery.


» Norris, Amer. Journ. Med. Sci., 1887, p.

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Norris, of Philadelphia, relates the following case, illustrating the
imminent danger to which even the life of the patient may be ex-
posed in those examples which are apparently the most simple.

William Summerill, 83t. 80, was admitted to the Pennsylvania
Hospital on the twentv-sixth of September, 1881. An hour previooa,
while descending a ladder, he slipped and fell in such a manner as to
throw the entire weight of his body upon the outer part of his left
foot. The foot was turned inwards, and nearly immovable; a slight
depression existed immediately below the lower end of the tibia, and
there was a hard rounded projection on the outer part of the foot, a
little below and in front of the extremity of the fibula ; the skin over
this projection was not broken or excoriated, but reddened ; there was
no fracture of either bone of the leg.

The symptoms rendered it plain that the astragalus was dislocated
forwards and outwards. Dr. Barton, under whose care the patient
was received, proceeded soon after to make attempts at reduction.
The muscles of the leg were relaxed as much as possible, and exten-
sion made from the foot by seizing the heel and front part of the foot
while an assistant made counter-extension at the knee. The bone was
also pushed inwards toward the joint by the surgeon. These efforts
were continued for a considerable time, but had no effect in changing
the {position of the bone.

Six hours afterwards, Drs. Harris and Hewson being in consulta-
tion, the attempt was again made to accomplish the redaction, bat
without success ; and the surgeons immediately proceeded to excise
the bone.

An incision was made parallel with the tendons, commencing a
I short distance above the projection, and extending down far enough to

expose fairly the astragalus and its torn ligaments. The bone was
then seized with the forceps and easily removed after the division of
a few ligamentous fibres that continued to connect it with the adjoin-
ing parts. Very little bleeding occurred, only two small arteries re-
quiring the ligature.

After removal, it was discovered that about one-half of the snr&oe
which plays in the lower end of the tibia had been fractured, and that
it remained firmly attached to the extremity of that bone. No at-
tempt was made to remove this fragment ; but^ the joint being care-
fully sponged out^ the sides of the wound were brought together and
closed by sutures, adhesive straps, and a roller ; after which the foot^
placed in its natural position, was laid in a fracture-box.

On the fifth day a slough began to form upon the outside of the
foot, which was followed by suppuration at other points, and on the
thirteenth day an opening was made to evacuate the pus near the
malleolus internus. At the end of about eight weeks the fragment
of the astragalus which had been suffered to remain was found to be
carious, and it was removed ; the heel also had ulcerated from pres-
sure, and several other bones of the tarsus were discovered to be ca-
rious. Fifteen months later, this poor fellow was still in the hospital,
suffering from hectic, with extensive disease in the bones of the tar-

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sua and ankle-joint. Finally, amputation of the leg was practised by
I> r. Barton, a few days after which he died^

!Korris mentions also two examples of simple dislocation of the as-
tra.galas at the Pennsylvania Hospital which came under the obser-
vation of Dr. Barton, in both of which the bone was left unreduced.
Tn one case inflammation and sloughing soon effected a complete ex-
posure of the protruding bone, but after a time the skin cicatrized. At
the end of five months the patient walked and had good use of the
joint, though great deformity of the foot existed, and he continued to
be subject to ulceration of the newly -formed skin on its outer part.
In the other case gangrene supervened soon after the accident, and
the patient died.

Norris adds that "the late Professor Wistar removed the astragalus
in a case of compound dislocation, and the patient was cured with
some motion at the joint."

Dr. Alexander Stevens, of New York, made the same operation in
a case of compound dislocation, and, after several months, he affirms
that the patient " has recovered with very trifling deformity of the
foot, and with a flexible joint. He walks with very slight lameness.'**
I am indebted to Dr. B. H. Hart, of Marietta, Ohio, for an account
of the following case, and for the specimen, which has, also, kindly
been put in my possession.

In June, 1868, Thomas Williams was thrown from his carriage,
alighting upon his left foot and causing a compound dislocation of the
ankle-joint. Dr. Hart was immediately called, and found the bones
of the leg thrust through the integuments on the outside, the malleo-
lus internus broken, and the astragalus partially dislocated. After
enlarging the opening in the integuments with a pocket-knife, the
doctor was able to reduce the dislocated bones to place. It must be

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 84 of 100)