Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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mentioned that this man weighed 226 lbs., and that in his fall he de-
scended a precipice or bank SO feet in height. Soon after the reduc-
tion the patient had two severe convulsions, which were arrested by
bleeding and opiates, and never returned. Cool lotions were applied
to the limb ; and on the sixth day erysipelas supervened and extended
nearly to the body. The erysipelas continued about nine days. Ex-
tensive suppuration throughout the joint resulted, and some fragments
of bone came away, and on the thirty-third day Dr. Hart removed,
without the aid of the knife, the entire astragalus. In three months
the patient walked upon crutches, and in eleven months he could walk
well without a staff, a slight motion having been preserved in the
ankle-joint.

The dislocations backwards, of which seven examples only have
been recorded, have all, with but one exception, been left unreduced ;
yet in at least four instances the patients have recovered with pretty
useful limbs. Such was the fact with Liston's and Lizar's patients,
aod also with Mr. Phillips' two cases, to all of which I shall again
refer. It must be noticed, however, that in each of. the cases men*

» Norris, Amer. Joum. Med. Sci., Aug. 1887, p. 878.

2 Stevens, North Amer. Med. and Surg. Journ., Jan. 1827, p. 200.



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732 TARSAL LUXATIONS.

tioned as followed by a successful termination without reduction, the
dislocations were simple.

Turner, of Manchester, has reported one example of compound
luxation outwards and backwards, in which, finding himself unable
to effect reduction, he removed the astragalus, with a tolerably success-
ful result.' Finally, a case was presented in one of the London hos-
pitals in 1839, of a dislocation inwards and backwards, which was
reduced in about ten minutes, by extension accompanied with lateral
pressure.'

In Sept. 1870, 1 saw, with Dr. Sayre, in consultation, a dislocation of
the astragalus forwards and outwards, in the person of Mr. Stewart,
of this city, which had just occurred in consequence of an injury re-
ceived in being thrown from a carriage. The dislocation seemed to
be nearly complete, causing great projection and tension of the skin.
Under the influence of chloroform, by extension and pressure, it was
easily reduced by Dr. Sayre. In five weeks from this time he was
able to walk, and soon after the restoration of the functions of the
joint was complete.

TVeatment, — Various attempts have been made by surgical, writers
to determine the line of treatment which should be adopted in these
unfortunate cases, but with very unsatisfactory results, since they are
far from having arrived at similar conclusions, nor have they been
able always to settle the question definitely for themselves. The diffi-
culty consists in the multiplicity and lack of uniformity in the com-
plications which attend these accidents, rendering it impossible to
establish a classification upon which a uniform treatment may be
safely based. There are certain principles, however, which seem to
be sufficiently settled to allow of an authoritative announcement:
these may be briefly stated as follows : If the dislocation is simple,
reduce the astragalus immediately, provided this is possible. If the
luxation is complete, and it cannot be reduced, even partially, proceed
at once to resection or to amputation. In compound dislocations^ re-
section or amputation affords the only safe resource. In all cases the
inflammation is likely to be intense, in order to prevent which com-
plication the surgeon must be unremitting in his use of the appropri-
ate remedies.

Out of eighteen cases of complete excision of the astragalus, collected
by Turner, fourteen made good recoveries, and in only one of these
fourteen was there anchylosis.

The several indications and rules of treatment above enumerated
we shall proceed to illustrate a little more fully.

In a recent simple luxation of the astragalus forwards, the leg
should be flexed to a right angle with the thigh, and, for the purpose
of making extension, one assistant should take hold of the foot with
both hands in the same manner that a servant draws a boot, that is,
with the right hand grasping the heel, and the left placed upon the

» Turner, Trans. Provin. Med. and Surg. Joum., vol. ix. Essay on Disloc. of
Astrag., with nearly fifty cases. For additional cases, see Med. and Surg. Reporter.
Jan. 18G7.

« London Lancet, vol. ii. p. 559.



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DISLOCATIONS OP THE ASTRAGALUS. 733

dorsum of the foot, near the toes. A second assistant should seize the
lower part of the thigh, in order to make counter-extension, while the
surgeon presses with the ball of his hand against the head of the as-
tragalus, upwards and backwards. If these 'simple measures fail, the
pulleys ought to be employed as a substitute for the:hahds in making
extension. In applying the extension, the toes must be kept well
down, and occasionally the foot should be moved gently from one side
to the other.

An oblique dislocation must be reduced, if possible, to an anterior
luxation, before an attempt is made to carry the head of the bone back
to its place, as by this mode the reduction will be greatly facilitated.
Lateral luxations may be reduced by the same means ; but if the
astragalus is dislocated outwards, the foot must be held forcibly ad-
ducted during the extension; and if it is dislocated inwardS; the foot
must be held strongly in 'the opposite direction.

Lizars says that he has seen one case of backward luxation, and
that all attempts at reduction were unavailing. The limb was, how-
ever, preserved, and proved to be useful.^ Liston was equally un-
successful in a case which came under his notice.' Phillips has
reported two cases, in neither of which was the reduction accom-
plished.^ N^laton has seen a compound dislocation which he could
not reduce.* Mr. Erichsen' however, who admits that when dislocated
backwards it has not hitherto been reduced, declares that the surgeons
at University Hospital have succeeded in one case recently, in which
both the tibia and fibula were broken also.'^ Mr. Erichsen suggests
also that, in case of a failure by the ordinary means, we should resort
to a subcutaneous section of the tendo-Achillis. Mr. Williams, of
Dublin, in a similar case, which had been left unreduced, was obliged
finally to extract the bone, in consequence of the integuments having
sloughed.*

Compound dislocations, and such as are otherwise complicated,
demand of the surgeion immediate amputation or exsection, the latter
of which ought to be preferred whenever the condition of the limb
encourages a reasonable hope that the foot may be saved.

Dr. Grant, of Canada, has recently reported a case, however, of suc-
cess after reduction of a compound dislocation of this bone. The man
was 85 years old, and in good health. Immediately after the accident
the astragalus was found completely dislocated forwards, and lying
with its long axis placed transversely, so that the anterior extremity
protruded through the integuments one inch on the outer side of the
foot. There was no fracture. The first attempt at reduction, by ex-
tension and pressure, failed; but in the second attempt moderate
pressure, without extension, was successful. Suppuration ensued, and
continued two months. At the end of eight months he walked with-

> Lizars, System of Practical Surg., Edinburgh ed., 1847, p. 161.
« Liston, Elements of Surgery, vol. iii. p. 348.
3 Phillips, Lond. Med. Gaz., vol. xiv. p. 596.

* N61aton, Pathologic Chirurg., t. ii. p. 482.

* Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 270.
s Williams, Erichsen, op. cit., p. 271.



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734 TABSAL LUXATIONS.

out a cane ; and at the date of the report the ankle was in all respects
perfect.*

When exsection is practised, and the bone is found to be broken,
as it often is, all the fragments should be carefully remored, since
they are certain to become necrosed if left in place. Nor ought the
surgeon to hesitate to lay open freely the tissues in every direction, in
order that he may accomplish this purpose ; even the tendons lying
over the protruding bone may be sacrificed unhesitatingly, since, after
having been so severely bruised, stretched, and lacerated, they are
pretty certain to slough. Ind^, the more freely the tissues are
divided over the bone, the less will be the danger of inflammation,
and the safer will be the life and limb of the patient.

In addition to the examples already cited of compound dislocation
in which the astragalus was removed, the following, reported by Dr.
W. A. Gillespie, of Ellisville, Ya., will also illustrate the occasional
value of exsection in these severe accidents.

Mrs. A., aged about fifty years, fell from a horse on the 2Sd of May,
1888, dislocating both ankles. The luxation of the right foot was
accompanied with a luxation of the astragalus outwards, which pro-
jected through a very large wound in the integuments, and its trochlea
was placed at an angle of about 46^ with its natural position. Early
on the following day it was removed by severing its few remaining
connections, and the wound was immediately closed by stitches, ad-
hesive plasters, and light dressings. From the moment of the receipt
of the injury, and for several days afterwards, she suftered excruciating
pain in the limb, and on the third day tetanus was apprehended, but
its full accession was prevented by the free use of opiates. The limb
was suspended in N. R. Smith's fracture-apparatus ; and as gangrene
with hectic fever soon threatened the life of the patient, fermenting
poultices were diligently applied, and the patient was sustained by
wine, bark, and other tonics. Two months after the injurv was re-
ceived, the date at which the report is given, the wound had entirely
healed, and her complete recovery was regarded as certain.' Many
other similar examples have been reported by foreign surgeons.

One word more with regard to the treatment of the wound after
excision. A considerable experience in accidents and wounds of this
class, that is, wounds accompanied with great contusion and lacera-
tion, has convinced me that the practice of closing the surface with
sutures, adhesive plasters, bandages, &c., is eminently pernicious.
The effusions which must necessarily occur, and which indeed we
think ought to occur, are thus imprisoned beneath the skin, giving
rise to swelling, pain, inflammation, and finally suppuration or slough-
ing. It is far better, in our opinion, to leave the wound open, covering
it only with cloths constantly kept moist with cool water. For this
latter purpose some mode of irrigation is preferable, as being more con-
stant and uniform. To those who have never adopted this treatment
of contused wounds, or of wounds generally, we would recommend an

1 Qrant, Canada Med. Joum., Oct. 1865.

s Gillespie, Amer. Joam. Med. Sci., Aag. 1838, p. 552.



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ASTRAGAL0-CAL0ANE0-8CAPH0ID DISLOCATIONS. 735

early trial, feeling confident that they will never have occasion to
iregret the experiment.

§ 2. ASTRAaALO-CALOANEO-SOAPHOID DISLOCATIONS.

It is perhaps quite as common for the astragalus to be dislocated
from the scaphoid bone and calcaneum, while it retains its connections
vrith the tibia, as to be luxated from all these bones at the same time.
This astragalo-calcaneo-scaphoid dislocation is that which Malgaigne
bas termed " sub-astragaloid." Produced by the same causes which
determine true dislocations of the astragalus, it may occur in the same
directions, and is liable to the same complications; nor will either the
prognosis or treatment diflfer essentially from that which is recognized
and established in the other accident.

As in dislocations proper of the astragalus, so also in this accident,
opposite results have occasionally followed from similar modes of
treatment. Thus, Dr. Detmold, of New York, stated in 1856 to the
New York Academy of Medicine, that he had recently met with a
dislocation of the astragalus, in which the bone retained its proper
relations with the tibia,, but not with the bones of the tarsus. The
patient had fallen from a wagon and caught his foot in the wheel.
Dr. Detmold made extension with pulleys, but could not effect the
reduction. Subsequently he was obliged to remove the astragalus on
account of the suppuration which followed and the consequent exposure
of the bone. The wound did not heal kindly, and at length amputa-
tion of the leg became necessary.

Dr. Detmold concludes, from this example and others which have
come to his knowledge, that if a similar case were to present itself to
him again, he would amputate at once.^

The following case, reported by Dr. Thomas Wells, of Columbia,
S. C, is of unusual interest, as illustrating the danger of leaving the
bone displaced, and also the benefit which may, even under the most
unfavorable circumstances, result from its final removal.

Dr. S., SBt. 80, was riding in an open carriage, some time during
the year 1819, when his horses became frightened and ran, and m
leaping from his vehicle he struck upon his left foot, dislocating the
astragalus from its junction with the scaphoid bone, upwards and
slightly outwards. Several medical gentlemen made violent efforts to
reduce the bone, but without effect. Inflammation and suppuration,
accompanied by a high fever, soon followed, and the head of the
astragalus becoming carious, protruded through the skin. On the
18th of August, about seven months after the injury was received, he
was still suffering from a copious discharge, pain, swelling, and general
irritative fever, and it was determined to excise the bone ; which was
accordingly done by enlarging the wound and detaching its loos«
connections with the adjacent tissues. The astragalus extracted left a
frightful wound, the foot seeming to be nearly separated from the leg.
A hollow splint was adjusted to the inside of the foot and leg, so as to

> Detmold, New York Joum. Med., May, 1856, p. 383.



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736 TARSAL LUXATIONS.

preserve the limb perfectly steady and in a proper direction ; simple
dressings were applied, and an anodyne administered internally. No
accidents followed, and at the end of September the wound was healed,
and the swelling of the parts had entirely subsided. One year after
the operation, he walked without the least difGiculty ; the ankle being
then " perfectly sound." The leg was shortened about one inch, and
this deficiency was supplied by a thick heel upon his shoe.^

Examples might be cited illustrative of the value of early exsection
where reduction could not be accomplished; but, after what has
already been said upon the subject of dislocations of the astragalus,
we shall not regard any farther reference as either necessary or osefuL
If other principles of treatment are to govern the surgeon than those
which we have already laid down, they cannot here be stated. They
are among those unwritten rules whose existence we cannot always
recognize until the case arises upon which they may apply. Yet, in
the exigency supposed, they are as clearly defined, and as imperative,
in the mind of the clever surgeon, as any of those laws which have
been made the subjects of special record.

§ 3. DlSLOOATIONS OF THE CaLOANEUM.

The calcaneum may, as a consequence of a fall upon the heel, or
of a direct blow, be dislocated outwards from the astragalus alone, or
upwards and outwards from the cuboid bone at the same time. It
has been found also at the same moment dislocated outwards from the
astragalus and inwards upon the cuboid bone.

Gbelius says he has seen an old dislocation of the calcaneum, pro-
duced in early life by pulling off a boot, from which there finally
resulted a degeneration like elephantiasis of the leg, rendering ampu-
tation necessary.*

Mr. South remarks, in his Notes to Chelius, that the two cases of
dislocation outwards of this bone, mentioned by Sir Astley Cooper,
were from his (South's) Notes (cases 199 and 200). In the first case,
that of Martin Bentley, occasioned by the falling of a heavy stone
upon his foot, the integuments were not broken, and the position of
the foot resembled a varus. *' The dislocation was easily redaced,
having bent the thigh and knee on the body and fixed the leg, by
laying hold of the metatarsus and of the tuberosity of the heel-bone,
and drawing the foot gently and directly from the leg, during which
extension Cline put his knee against the outside of the joint, and the
foot being pressed against it, the heel and the navicular bone readily
slipped into their place, and the deformity disappeared." He was
discharged from the hospital in five weeks, " having the complete use
of his foot."

* In the second oasC; the dislocation, produced also by the fall of a
stone upon the foot, was compound, and the patient, Thomas Gilraore,
having been brought into St. Thomas's Hospital, the reduction was

> Wells, Amer. Journ. Med. 8d., May, 1833, p. 21.
Chelius, System of Surg., Amer. ed., toI. ii. p. 8M.



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DISLOCATIONS OF THE OS SOAPHOIDES. 787

effected by extending the foot and rotating it outwards. Six months
after, when he left the hospital, he was able to walk pretty well with
a stick.

§ 4. Middle Tabsal Dislocations.

The scaphoid and cuboid bones may be dislocated from the astra-
galus and calcaneum, constituting what is termed, by Malgaigne, a
middle tarsal dislocation. It is probable that, to some extent, the same
tbin^ has occurred in many of those cases which are reported as sim-
ple dislocations of the astragalus, or as dislocations at the astragalo-
scaphoid articulation ; but it occurs also occasionally in a degree so
perfect and complete as to leave no doubt as to the true nature of the
disjunction, and to entitle it to a separate consideration.

Mr. Listen mentions the case of a boy, sBt. 14, who fell from a height
of forty feet, striking, apparently, upon the extremity of the foot
The scaphoid and cuboid bones were found to be displaced upwards
and forwards, so that the foot was shortened about half an inch, and
had a clubbed appearance. No attempt was made to reduce the bones,
and he left the hospital in three weeks, able to stand on the foot.^ Sir
Astley Cooper has recorded in more detail a similar example. A man,
working at the Southwark bridge, London, received upon the top of
his foot a stone of great weight. He was immediately carried to Guy's
Hospital, and his condition is described as follows: "The os calcis
and the astragalus remained in their natural situations, but the fore-
part of the foot was turned inwards upon the bones. When examined
by the students, the appearance was so precisely like that of a club-
foot, that they could not at first believe but that it was a natural defect
of that kind ;" but, upon the assurance of the man that previously to
the accident his foot was not distorted, extension was made, and the
reduction was effected. He was discharged from the hospital in five
weeks, having the complete use of his foot."

§ 5. Dislocations of the Os Cuboides.

According to Pi&lagnel, quoted by Chelius, the cuboid bone may
be dislocated upwards, inwards, and downwards, but Malgaigne aflSrms
that he has found no case recorded in which the dislocation has oc-
curred alone, or unaccompanied with a dislocation of one or more of
the other tarsal bones.

§ 6. Dislocations of the Os Soaphoides.

Burnett has seen a luxation of the scaphoid bone in which its con-
nections with the astragalus were undisturbed, while at the same time
it was completely separated from the cuneiform bones. By strong
pressure exercised during several minutes, the os scaphoides was
made to fall into its place. The dislocation was compound, yet the

> Practical Surgery 'also London Lancet, vol. xxxvii. p. 183.
s Bir A. Cooper on Disloc, &c., London ed., 1823, p. 876.



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788 TARSAL LUXATIONS.

wound healed rapidly, and in a abort time the reooverj was almost
complete.^

Several examples are recorded of a true luxation of the os 9ca-
phoides, in which the bone had abandoned both the astragalus on the
one hand, and the cuneiform bones on the other.

Pi^dagnel mentions a case in which the scaphoid bone was broken
longitudinally, and its internal fragment, constituting the largest por-
tion, was displaced inwards through a tegumentary wound. He was
unable to efiect reduction, and was compelled to amputate the foot.'

Walker has reported the first example of luxation forwards, occa-
sioned by jumping upon the ball of the foot The bone formed a
marked projection upon the top of the foot, and a corresponding de-
pression existed below. An attempt was first made to accomplish
the reduction by simple pressure with the thumbs ; but this having
failed, the surgeon bent the extremity of the foot forcibly downwards,
and by continuing to press upon the os scaphoides, it fell into its posi-
tion easily and with a distinct click. In about three weeks the patient
was able to walk with only a slight halt, and no deformity remained.'

§ 7. Dislocations or ths Cuneivobm Bones.

The cuneiform bones may be luxated partially, and without having
separated from each other, of which two or three examples are re-
corded ; or, which is more common, the cuneiforme internum may be
luxated alone. Says Sir Astley Coop)er: "I have twice seen this
bone dislocated ; once in a gentleman who called upon me some weeks
after the accident, and a second time in a case which occurred in Guy's
Hospital very lately. In both instances the same appearances pre-
sented themselves. There was a great projection of the bone inwards,
and some degree of elevation, from its being drawn up by the action
of the tibialis anticus muscle ; and it no longer remained in a direct
line with the metatarsal bone of the great toe. In neither case was
the bone reduced ; the subject of the first of these accidents walked
with but little halting, and I believe would in time recover the use of
the foot, so as not to appear lame. The cause of the accident was a
fall from a considerable height, by which the ligament was ruptured
which connects this bone with the os cuneiforme, and with the os
naviculare. The second case, which was in Guy's Hospital, my ap-
prentice, Mr. Babington, informs me, happened by the fall of a horse,
and the foot was caught between the horse and the ourb-stone."^

In a case of compound luxation seen by Mr. Key, reduction was
effected, and in two months the cure was so far completed that the
patient walked with only a slight lameness.' Ndlatoo, in a similar
ciise of compound luxation, unable to reduce the bone, removed it
completely, and the patient recovered.*

1 Burnett, Lond. Med. Gazette, 1S37, vol. xix. p. 2S1.
« Pi^dagnel, Journ. Univ. et Heb., torn. ii. p. 208.
» Walker, The Medical Examiner, 1851, p. 203.

* Sir Ast. Cooper, op. cit., p. 388.

» Kev, Guy's Hoap. Rep., 1836, vol. i. p. 544,

* N^laton, Malgaigne, op. cit., p. 1076.



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DISLOCATIONS OF THE CUNEIFORM BONES. 739

Bobert Smith has oalled attention to a species of dislocation of the
internal cuneiform bone not before very accurately described ; but of
^hich he has presented two examples. It consists in simultaneous
dislocation of the metatarsus and internal cuneiform ; that is to say, the
£rst metatarsal bone, together with the internal cuneiform, is dislocated
upwards and backwards upon the tarsus, carrying with it also the four
remaining metatarsal bones. In both of the examples seen and re-
corded by him, the dislocations were ancient, and no account could be
obtained of the precise manner in which the accidents had been pro-
duced. The feet were foreshortened to the extent of an inch or more,
in consequence of the overlapping of the bones, yet the heel in each
case preserved its natural relations to the tibia, not being proportion-
ately lengthened as is the case in dislocations of the tibia forwards.
The plantar surface of the foot was turned inwards, and instead of
being concave it was convex, both in its antero-posterior and trans-
verse diameters. A transverse ridge on the top of the foot also indi-
cated the line of the projecting bones. Both of these cases were veri-
fied by a careful dissection.*

Dupuytren has reported in his Treatise on Injuries of the Bonesj a
similar case, occurring in a woman, eet. 80, who was brought immedi-
ately to Hdtel Dieu. She stated that in descending from the bridge
of St. Michael, with a burden of two hundred pounds, she fell in such



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 85 of 100)