Treatment.—In those cases of fracture of the lower end of the fibula in which there is no marked displacement,—and they constitute a considerable proportion,—the limb should be massaged and laid on a pillow between sand-bags, or placed in a box splint for two or three days, until the swelling subsides. Some form of rigid apparatus, such as side poroplastic splints fixed in position with an elastic bandage, which will allow the patient to get about with crutches, is then applied. This is removed daily to permit of massage and movement being carried out—a point of great practical importance, because, if this is neglected, not only does union take place more slowly, but the stiffness of the ankle and œdema of the leg and foot which ensue, prolong the period of the patient's incapacity and endanger the usefulness of the limb.
It is in cases of this kind that the ambulatory method of treatment yields its best results. When, in the course of two or three days, the swelling has subsided, a plaster-of-Paris case ([Fig. 95]) is applied in such a way that when the patient walks the weight is transmitted from the condyles of the tibia through the plaster case to the ground, no weight being borne by the bones at the seat of fracture. The apparatus is applied as follows: A boracic lint bandage is applied to the limb as far as the knee, and protecting pads or rings of wool are placed over the condyles of the tibia, the head of the fibula, and the malleoli. A pad of wool about 3 inches thick is then placed under the sole and fixed in position by a plaster-of-Paris bandage, which is carried up the limb in the usual way. The case is made specially strong on the sole, around the ankle, up the sides of the leg, and at the bearing-point at the head of the tibia. After the plaster has thoroughly set, the patient is allowed to walk about with a stick, crutches being unnecessary. In the course of three weeks the plaster case may be removed and the limb massaged. It is usually found that the movements of the ankle are scarcely interfered with, and the patient is generally able to resume work within a month of the accident.
Fig. 95.—Ambulant Splint of plaster of Paris.
Fig. 96.—Dupuytren's Splint applied to correct eversion of foot.
When there is marked eversion of the foot, it may be necessary to administer a general anæsthetic to reduce the deformity; and to prevent recurrence of the displacement Dupuytren's splint ([Fig. 96]) may be used. This splint, which is of the same shape as Liston's long splint, but on a small scale, is applied to the medial side of the leg extending from just below the knee to well beyond the sole of the foot. A large pad is placed in the hollow above the medial malleolus, and it must be thick enough to carry the splint so far from the limb that when the foot is fully inverted it does not touch the splint. The upper end of the splint having been fixed to the leg at the level of the condyles of the tibia, a bandage is applied to correct the eversion of the foot, and at the same time to support the heel, and, as far as possible, to overcome the pointing of the toes. Care must be taken to avoid carrying the turns of this bandage over the seat of fracture. The limb may then be slung in a cradle, or placed on a pillow resting on its lateral side with the knee flexed. In the course of a few days, a poroplastic splint may be substituted and massage commenced.
When backward displacement of the heel is the prominent deformity, Syme's horse-shoe or stirrup splint ([Fig. 97]) may be employed. It is applied to the anterior aspect of the limb, which is carefully padded to prevent undue pressure on the edge of the shin bone. After the upper end of the splint has been fixed, the heel is pulled forward by a few turns of bandage passed over the prongs at the lower end of the splint. The foot is then inverted and brought up to a right angle by a few supplementary turns of the bandage. In a few days this appliance may be replaced by a poroplastic splint.