MEMOIR XVI.
ON THE FRACTURE OF THE OS CALCIS.
§ I.
1. The os calcis, being a short and thick bone, has such a power of resistance, that it is but seldom fractured. Such an accident does, however, sometimes occur, and may arise from two causes, 1st, the action of external bodies, which is rare: 2dly, the contraction of the gastrocnemii and soleus muscles, from which it almost always proceeds. Thus, the rotula is more frequently broken by the action of the extensor muscles, than by blows received on the bone from without: there is, however, this difference between the effects of muscular contraction in these two cases, namely, that in the former, the rupture of the tendo Achillis is common, and the fracture of the os calcis very rare; whereas in the latter, on the contrary, the rotula is oftentimes broken, while the tendon of the extensors remains almost always sound. This phenomenon is explained by the difference between the thickness of the two bones, between the length of the two tendons, and between the power of the causes.
2. Be the cause of the fracture what it may, it generally occurs in that portion of the os calcis, called its great tuberosity, which projects behind the astragulus, which corresponds above and below to a large quantity of cellular membrane, inwardly to the great groove of the bone, externally to some ligamentous attachments, and behind to the insertion of the tendo Achillis.
3. It is known, 1st, by an evident inequality under the heel: 2dly, by an elevation, sensible to the touch, of the posterior fragment above its usual level: 3dly, by an almost entire inability either to stand or walk: 4thly, by severe pain being the inevitable consequence of moving the foot: 5thly, by its being practicable to increase the displacement by flexing, and to diminish it by extending the foot: 6thly, by the facility with which the posterior fragment may be moved in every direction by taking hold of it with one hand, and steadying the foot with the other: 7thly, by a swelling more or less considerable, which frequently appears around the divided surfaces.
4. The ancients gave in general an unfavourable prognosis respecting this kind of fracture. Hippocrates was apprehensive of some injury being done to the surrounding parts. Pare considered the case mortal, on account of the laceration of numerous vessels which are connected with the bone. Most of the moderns adopt these principles, not for the foregoing reasons, but on account of the vicinity of the accident to the joint of the foot. The practice of Desault cannot throw much light on this subject, as he never had more than one or two such cases of fracture under his care; but the analogy of other fractures, situated in the neighbourhood of joints and even extending into them, induces us to believe, that, if properly treated, fractures of the os calcis will terminate as favourably as those of other bones.
§ II.
5. If we attend to the signs just mentioned (3), we will perceive that they almost all result from the displacement of the fragments. But, whence arises this displacement? As far as the anterior fragment is concerned in it, it arises from, and is increased by, the flexion of the foot; and, as far as relates to the posterior one, it is to be attributed to the contraction of the muscles attached to the tendo Achillis, which is itself inserted in that fragment. Hence it follows, that the apparatus intended to prevent this displacement, ought, 1st, to keep the foot permanently extended on the leg: 2dly, to prevent the action of the muscles, by keeping them in a state of habitual relaxation by means of the constant flexion of the leg on the thigh, by making on those whose contractions are dreaded, such a regular and well directed compression as may disqualify them for contracting; and, lastly, by placing behind the posterior fragment some resisting substance, to prevent it from rising upwards.
6. If to these indications we compare Desault’s apparatus for a rupture of the tendo Achillis, as described in the preceding memoir, we will readily perceive 1st, that it perfectly fulfils that indication which relates to the anterior fragment; 2dly, that that one which relates to the posterior fragment will be equally well fulfilled by the half flexed state of the leg, by the compression made on the muscles, and by a thick compress, not very broad, laid transversely above the fragment, secured by the long roller, and afterwards by a circular bandage, which must form here, as in the case of a fractured rotula, a kind of figure of 8 around the fracture. This compress is the only modification of the apparatus requisite to accommodate it to the particular case now under consideration.
7. In applying the figure of 8 bandage here, as well as in the case of a fractured rotula, to prevent the ascent of the fragment, it is necessary to use the utmost care to free the integuments from wrinkles both above and below the fracture, lest by getting between the fragments, they might keep them asunder, and thus impede their reunion.
8. Desault used to relate in his lectures, the case of a woman whom he had formerly seen receiving a fracture of the os calcis, by falling from a great height. I cannot state the case fully, because I am not in possession of all the facts. The following one however drawn up during the first years of Desault’s practice in the Hotel-Dieu, will furnish an example of his mode of treatment.
Case. A man, likely to be arrested by some one who pursued him, leapt from a window nearly twelve feet high. In lighting, his feet struck on a beam which lay in his way, in such a manner, that the fore part of them only was supported. He made an effort to recover his equilibrium, but as the line of gravity of his body had nothing to rest on, he fell backwards, rose in order to make his escape, but fell a second time unable to rise again.
When assistance came to him, he complained of a severe pain in his heel, and said, that on falling, he had heard a considerable report. He was taken up, and assisted in walking to the Hotel-Dieu, where he did not arrive without pain, being able to bear only on the point of the diseased foot, and suffering greatly if he attempted to put his heel to the ground.
From the signs mentioned (3), Desault perceiving that there existed a fracture of the os calcis, made arrangements for reducing it. This he did by extending the foot on the leg, and drawing down the exterior fragment from the elevation to which muscular contraction had raised it, so as to bring it into perfect contact with the body of the bone. He then applied the common apparatus for a rupture of the tendo Achillis, with the modification already pointed out (6).
In the evening venesection was prescribed: the patient experienced sharp pains at the place of the fracture; a slight swelling occurred at the ends of the toes; an anodyne was prescribed. Next day, evidently better: venesection again. Fourth day, the patient is allowed to return to his usual regimen. Eighth day, apparatus removed for the first time; fragments in contact. Fifteenth day, a second application of the bandage. Nineteenth day, bilious symptoms. Twenty-first, an emetic given in solution. Thirty-second day, further evacuations: apparatus renewed. Forty-seventh day, consolidation complete. A stiffness remained in the part for some time, but this was gradually removed by exercise.