Manual of Surgery Volume II Part 19

To effect reduction, the quadriceps must be thoroughly relaxed by extending the leg upon the thigh and flexing the thigh upon the pelvis; the patella is then tilted by making firm pressure on that edge which lies farthest from the middle of the joint, and at the same time pus.h.i.+ng towards the middle line. The limb is placed on a posterior splint, and firm elastic pressure made on the joint to prevent or diminish effusion. Ma.s.sage and movement are carried out from the first.

As the displacement is liable to recur, the patient should wear a firm elastic bandage or a strong knee-cap.

_Permanent and recurrent dislocation of the patella_ will be described later.

FRACTURE OF THE BONES OF THE LEG

The bones of the leg may be broken together or separately.

#Fracture of both Bones.#--The features of this injury depend to a large extent upon the nature of the violence producing it. In fracture by _direct_ violence, such as the pa.s.sage of a wheel over the limb or a severe blow, the bones give way at the point of impact, and the line of fracture tends to be transverse, both bones being broken at the same level (Fig. 89). There is little or no displacement, and such as there is is angular, and is determined by the direction of the fracturing force.

[Ill.u.s.tration: FIG. 89.--Radiogram of Transverse Fracture of both Bones of Leg by direct violence.]

When the violence is _indirect_, as from a fall on the feet, or a twist of the leg, the tibia usually gives way at the junction of its lower and middle thirds, and the fibula at a higher level (Fig. 90).

Torsion of the tibia is probably the most important factor in the production of the fracture, the distal fragment being fixed by the pressure of the foot upon the ground, while the proximal fragment is rotated by the impetus of the body. Both fractures are usually oblique--that in the tibia running from above downward, forward, and medially, and it is generally found that the obliquity of the fibular fracture corresponds with that in the tibia.

[Ill.u.s.tration: FIG. 90.--Radiogram of Oblique Fracture of both Bones of Leg by indirect violence.]

There is usually considerable displacement, the weight of the lower portion of the limb causing it to fall backwards and to roll away from the middle line, and the traction of the calf muscles pulling up the heel and pointing the toes. The proximal fragment forms a projection on the front of the limb.

On account of the superficial position of the tibia and the pointed character of the fragments, this fracture is frequently rendered compound by the bone being forced through the skin. The projecting piece of bone is usually the distal end of the proximal fragment. This fracture is often comminuted. It has been observed that when the line of fracture forms the letter V on the subcutaneous surface of the tibia, there is invariably a fissure pa.s.sing down along the back of the bone into the ankle-joint--a complication which adds to the risk of subsequent stiffness and impaired usefulness of the limb. Apart from this, the ankle is usually sprained in fractures by indirect violence, and we have frequently found the superior tibio-fibular articulation torn open in severe fractures of both bones of the leg from indirect violence.

_Clinical Features._--The tibial fracture is readily recognised by detecting an irregularity on running the fingers along the crest of the s.h.i.+n, and at this point abnormal mobility, tenderness, and crepitus can usually be elicited. It is often difficult to detect the fibular fracture, and it is not always advisable to attempt to do so, especially if the manipulations cause pain or tend to increase the displacement. The condition of the fibula is usually to be inferred by noting the amount of displacement and the extent of mobility of the tibial fragments. Not infrequently the seat of fracture may be recognised by locating a point at which pain is elicited on making pressure over the bone at a distance--pain on distal pressure.

On account of the close connection of the skin to the periosteum on the subcutaneous aspect of the tibia, the tension caused by extravasated blood is often extreme; blisters frequently form over the area of ecchymosis, and when these become infected, sloughing of the skin may take place and the fracture thus be rendered compound.

The vessels and nerves of the leg are seldom seriously damaged.

_Treatment._--If there is marked displacement, reduction is most satisfactorily accomplished under anaesthesia. Traction is made upon the foot and the fragments are manipulated into position, the pointing of the toes and the outward rotation of the foot being at the same time corrected. The normal outline of the foot in relation to the leg is restored when the ball of the great toe, the medial malleolus, and the medial edge of the patella are in the same vertical plane. As in other fractures of the lower extremity, the limb should be placed in the natural position of slight eversion: not with the toes pointing straight forward.

The retentive apparatus to be applied depends upon the tendency to re-displacement, the degree of swelling, and the extent of the damage to the skin.

In the average case, the leg is supported between sand-bags, and ma.s.sage and movements are employed from the outset. When there is a tendency to re-displacement, the limb may be immediately enclosed in a rigid apparatus, such as lateral poroplastic splints retained in position by an elastic bandage, or a Cline's splint, which can readily be removed to admit of ma.s.sage. When the fracture is in the lower third of the leg, the ambulatory splint gives excellent results, and is of special service in hospital practice (Fig. 95).

As an emergency appliance, for example for purposes of transport, the _box splint_ (Fig. 91) is simple and efficient. We have not found it effectual in controlling the fragments, particularly in oblique fractures, and it requires constant supervision and readjustment. It consists of two pieces of wood extending from above the knee to an inch or two beyond the sole, and a little broader than the maximum diameter of the leg. These are rolled into the opposite ends of a folded sheet, so as to form two sides of a box, of which the sheet const.i.tutes a third side. It is found advantageous to insert another board, fitted with a foot-piece, between the folds of the sheet forming the third side of the box, to add to the rigidity of the splint, and to aid in controlling the foot. By folding one side of the sheet somewhat obliquely, the box is made a little wider at the knee than at the ankle, and so fits the limb more accurately.

[Ill.u.s.tration: FIG. 91.--Box Splint for Fractures of Leg.]

The limb is placed in this box, the sides of which have been carefully padded. Ring pads are applied to take pressure off the condyles, the head of the fibula, the malleoli, and the prominence of the heel, and a large supporting pad is placed behind the tendo calcaneus. A folded towel is laid over the front of the leg, forming a lid to the box, and the whole is bound to the limb by three slip-knots. Finally, the foot is fixed at right angles to the leg and slightly abducted by a figure-of-eight bandage or a piece of elastic webbing. Sand-bags placed alongside serve to steady the limb. In fractures of the lower third of the leg, the box splint may stop short of the knee and the limb may then be suspended in a Salter's cradle, which allows the patient to move about more freely in bed.

[Ill.u.s.tration: FIG. 92.--Box Splint (applied).]

To prevent shortening in oblique fractures and in those near the ankle-joint, where it is often difficult to control the lower fragment, extension, applied by weight and pulley, or through a Thomas' knee splint, may be of service. The strapping may be applied only to the distal fragment, but we prefer to carry it to the upper third of the leg. If the overriding of the fragments persists, extension may be taken directly from the bone, the ice-tong callipers gripping the malleoli or the calcaneus.

When the skin is damaged, as it so frequently is on the medial aspect of the tibia, means must be taken to prevent infection.

Ma.s.sage is carried out daily, and, to prevent stiffness, the ankle is moved from the first. In the course of three weeks, lateral poroplastic splints retained by an elastic bandage may be subst.i.tuted, and the patient allowed up on crutches. In simple fractures without displacement, union is usually complete in from six to eight weeks, but when the fracture is oblique, comminuted, or compound, union is often delayed, and the functions of the limb may not be fully regained for three or even four months after the accident.

_Operative Treatment._--When overriding cannot otherwise be corrected, it is advisable to replace the fragments by operation. A curved incision with its convexity backward is made over the medial side of the tibia, exposing the fragments, which are then levered into position and if necessary plated or otherwise fixed according to circ.u.mstances. It is seldom necessary to deal separately with the fibula. A box splint is applied till the wound has healed, after which a poroplastic splint is subst.i.tuted and ma.s.sage commenced.

We do not share in the dissatisfaction expressed by some surgeons, notably Arbuthnot Lane, as to the results obtained by non-operative means in the common fractures of the leg, and do not recommend a systematic resort to operative treatment.

_Un-united fracture_ of the bones of the leg is sometimes met with. It is treated on the same lines as in other situations, but may prove extremely intractable, especially in children, in whom, indeed, it is sometimes incurable.

_Mal-union_, on account of the disability it entails, may call for operative treatment in the form of osteotomy of one or both bones.

_Compound fractures_ of the leg are common, and are treated on the lines already laid down for the treatment of compound fractures in general (p. 25).

#Fracture of the tibia alone#, when due to direct violence, is usually transverse, there is little displacement, and as the fibula retains the fragments in position, union usually takes place rapidly and without deformity. Oblique and spiral fractures result from indirect violence.

#Fracture of the fibula alone# may result from direct violence, and, on account of the support given by the tibia, is usually unattended by displacement. Bennett of Dublin has pointed out that it is common to meet with an oblique fracture of the upper third of the fibula as the result of an outward twist of the ankle while the foot is extended. It is characterised by pain localised at the seat of the break, on moving the foot in such a way as to bring the talus to bear against the fibula. Local pressure also may make the fibula yield and may elicit crepitus. In some cases this fracture is a.s.sociated with sprain of the ankle-joint. It is often overlooked, and from want of proper treatment may result in prolonged impairment of usefulness.

Fractures of the tibia or fibula alone are treated on the same lines as fractures of both bones, and splints are rarely necessary. The ambulant method is useful in these cases (Fig. 95).

CHAPTER VIII

INJURIES IN REGION OF ANKLE AND FOOT

Surgical Anatomy--FRACTURES: _Pott's fracture_; _Converse of Pott's fracture_; _Separation of lower epiphysis_; _Fracture of talus_; _Fracture of calcaneus_; _Fractures of other tarsal bones_; _Fractures of metatarsal bones_; _Fractures of phalanges_--DISLOCATIONS: _Of ankle joint_; _Of inferior tibio-fibular joint_; _Complete dislocation of talus_; _Sub-taloid dislocation_; _Medio-tarsal dislocation_; _Tarso-metatarsal dislocation_; _Dislocations of toes_.

The fractures in this region include Pott's fracture, and its converse; separation of the lower epiphysis of the tibia; fractures of the talus, calcaneus, and other tarsal bones; and fractures of the metatarsals and phalanges. Various dislocations also occur, the most important being those of the ankle joint, of the talus, and the sub-taloid dislocation.

#Surgical Anatomy.#--For the study of injuries in the region of the ankle-joint it is of importance to define the terms employed in describing the movements of the foot. Thus by _flexion_ or _dorsiflexion_ is meant that movement which approximates the dorsum of the foot to the front of the leg; while _extension_ or _plantar flexion_ means the drawing up of the heel so that the toes are pointed. In _inversion_ the medial edge of the foot is drawn up so that the sole looks towards the middle line of the body, an att.i.tude which is a.n.a.logous to supination of the hand. In _eversion_ the lateral edge of the foot is drawn up, the sole looking away from the middle line--a.n.a.logous to p.r.o.nation of the hand. _Adduction_ indicates the rotation of the foot so that the toes are turned towards the middle line of the body; while in _abduction_ the toes are turned away from the middle line.

The most prominent bony landmarks in the region of the ankle are the two _malleoli_, the lateral lying slightly farther back, and about half an inch lower than the medial. On the medial side of the foot from behind forward may be felt the _medial process (internal tuberosity)_ of the calcaneus; the _sustentaculum tali_, which lies about 1 inch vertically below the tip of the malleolus; the _tubercle of the navicular_, about 1 inch in front of the malleolus, and at a slightly lower level; the _first (internal) cuneiform_, and the base, shaft, and head of the _first metatarsal_.

On the lateral side may be recognised the _lateral process (external tuberosity)_ of the calcaneus; the _trochlear process (peroneal tubercle)_ on the same bone; the _cuboid_; and the prominent base of the _fifth metatarsal_.

The talo-navicular joint lies immediately behind the tuberosity of the navicular, and a line drawn straight across the foot at this level pa.s.ses over the calcaneo-cuboid joint.

The _ankle-joint_, formed by the articulation of the tibia and fibula with the talus, lies about half an inch above the tip of the medial malleolus, and is so constructed that when the foot is at a right angle with the leg it is only possible to flex and extend the joint.

When the toes are pointed, however, slight side-to-side and rotatory movements are possible. The chief seat of side-to-side movement of the foot is at the talo-navicular and calcaneo-cuboid articulations--"the mid-tarsal or Chopart's joint."

The ankle-joint owes its strength chiefly to the malleoli and the collateral ligaments, and to the inferior tibio-fibular ligaments, which bind together the lower ends of the bones of the leg. The numerous tendons pa.s.sing over the joint on every side also add to its stability.

The synovial membrane of the ankle-joint pa.s.ses up between the bones of the leg to line the inferior tibio-fibular joint; but it is distinct from that of the intertarsal joints, which communicate with one another in a complicated manner. The epiphysial cartilage at the lower end of the fibula lies on the level of the talo-tibial articulation, while that of the tibia is about half an inch higher (Fig. 93).

[Ill.u.s.tration: FIG. 93.--Section through Ankle-Joint showing relation of epiphyses to synovial cavity.

_a_, Lower epiphysis of tibia.

_b_, Lower epiphysis of fibula.

_c_, Talus.

_d_, Calcaneus.