The principles and practice of modern surgery

by Roswell Park

The foot should always be placed at a right angle to the leg. If there be too much muscle spasm to permit this, or make it too uncomfortable, the tendo Achillis may be divided. This position should be maintained during the period of repair, in order that so soon as one resumes the use of the limb the foot may be planted naturally upon the ground. In addition to this precaution it must be noted that backward displacement is completely overcome, and that eversion is perhaps a trifle overcorrected.

In all fractures of the lower end of the leg the foot and entire leg should be enclosed in a bandage. In fractures near or above the middle not only the leg but the lower part of the thigh should be immobilized if the promptest and most satisfactory results are to be obtained.

The limb being immobilized it soon becomes a question as to how quickly the patient can leave the bed and begin to move about on crutches. This will depend to some extent on the patient’s temperament. Timid women are less desirous of getting out of bed than are active men and children. Some patients acquire facility with crutches very slowly. Others are so tenderly built that crutches give pain and even produce crutch paralysis. It is advisable to get patients at least into the sitting posture so soon as the immobilization has been secured, while those inclined may be encouraged to use the uninjured limb and move about with crutches. A foot and leg too long kept off the ground will swell when again lowered. The later this dependent position is attained the greater the liability to edema. Patients should be cautioned about this.

The so-called ambulatory method of treatment has found favor with some surgeons. This implies something more than merely permitting motion with crutches; it means really such dressing as to permit use of the injured limb in locomotion. The various forms of splints used for immobilizing the limb in hip-joint disease may be used in this way. A useful splint is made with body and perineal bands, or an inside steel bar with ischiatic crutch and a cross-bar below the sole of the foot, on which the weight of the body may be supported. This is to be combined with a plaster-of-Paris support.

The ambulatory treatment is occasionally of value, but the advantages claimed for it have not been generally sustained.

FRACTURES OF THE FOOT.

The astragalus and the calcis suffer more often than the other tarsal bones, partly because of their size and partly because they are in the line of transmission of force as usually directed after accident. When the posterior end of the calcis is broken off there remains a fragment which is easily palpated, and which would be displaced backward and upward by the tendo Achillis were it not for the plantar fascial fibers which are inserted into it. The bone may also be comminuted, in which case that part of the foot will lose much of its shape and distinctive peculiarities. The sole will be flattened, but swelling and hemorrhage will at first be so great that there will be much difficulty in recognizing the exact nature of the injury.

The astragalus is usually broken by being caught between the calcis and the lower end of the leg. It is generally broken through the line of its so-called neck. Not infrequently one or more of the fragments is forced out of place, usually beneath the anterior tendons. When such extensive displacement occurs the fragments should be removed if the fracture is compound. In both of these bones results are generally satisfactory when displacement is not marked, also after removal of the entire astragalus. The foot and leg should be immobilized in the best possible position, and this can be best accomplished within a plaster-of-Paris dressing.

In regard to the tarsal bones, diagnosis can now be made accurately by the use of the x-rays. These bones, according to Eisendrath, may be fractured in any one of the following ways: (1) Compression, as when the weight of the body is violently thrown upon the feet; (2) sudden dorsal flexion, often with fracture of the inner malleolus; (3) forced supination or pronation, the interosseous ligaments being stronger, the bones forcibly pulling the latter apart; (4) violent traction upon the heel through the calf muscles, by which the tuberosity of the calcis may be torn from the rest of the bone; (5) extensive crushing injuries, in which several tarsal bones may be involved; (6) gunshot fractures. Some assistance in diagnosis may be obtained by computing the distance from the malleoli to the bottom of the heel, which will be shortened when the bones are compressed; or shortening of the length of the foot, or by fixed abnormal positions.

The metatarsal bones are broken by direct violence, the first and fifth being most exposed. As in other fractures of the foot contusion will be a serious feature, and swelling and laceration will frequently seriously complicate, while the fractures themselves may be compound. The same is true, also, of fractures of the phalanges, crushing and comminution being common. The matter of treatment often includes an estimation of the blood supply and of the vitality of the distal portion. The operator may sometimes temporize with an antiseptic dressing until this matter is settled. Simple fractures require only immobilization in good position.