—Non-operative treatment consists in sufficient limitation in the motion of the joint with abstention from use of it. In cases not amenable to non-operative measures the joint may be opened and the cartilage fastened in place to the head of the tibia either with absorbable or non-absorbable sutures.
The Fibula.
—The upper end of the fibula, although firmly bound to the tibial head, may be dislodged by direct or indirect violence. Forcible inward rotation of the foot, in full extension, will sometimes displace it forward, while forcible traction on the biceps may dislocate it backward. Displacements at this joint may occur when the leg bones are broken, while when the tibia alone is broken and shortened upward displacement may occur in consequence. Should displacements be discovered it will not be difficult by traction upon the foot and leg, in the normal direction, and by pressure to replace them. The backward displacement is the more unstable of the two. The lower end of the fibula is by itself rarely dislocated or distorted except in connection with violent sprains, accompanied by the laceration of ligaments or fracture of one or both bones.
DISLOCATIONS OF THE FOOT.
Backward and forward displacements of the foot are possible without fracture; as, for instance, when violence is applied to the leg after the foot is caught and fixed. Even here, however, the lateral ligaments must suffer partial or complete laceration, while one or both malleoli may be broken. The most frequent displacements of the foot are those which accompany and are permitted by fractures of the lower part of the leg, notably that originally described by Pott, with its troublesome form of bone lesions. An inward dislocation of the foot is described as produced by extreme supination and adduction.
It is necessary in studying these injuries to the ankle region to make out the existence of fracture, if any be present, as the treatment hinges largely upon such complication.
The astragalus may be dislocated from its relations with the lower ends of the leg bones, as the result of wrenches or twists or of violent injuries, as falls or blows upon the feet. When displaced it is nearly always forward. A backward dislocation is exceedingly rare. The rest of the foot itself is sometimes dislocated backward beneath the astragalus, although some portion of its lower surface still remains in contact with the upper surface of the calcis. These displacements occur in consequence of combined torsion and excessive violence. The foot here will be shortened anteriorly. No matter in what direction the astragalus may be displaced it is easily recognized.
Treatment.
—Reduction of ankle-and-foot dislocations accompanied by fracture is not a difficult matter, although their retention may be; but astragalus dislocations which are complicated are usually difficult of replacement. They will require relaxation of muscle tension by anesthesia or tenotomy and forced manipulations. When accomplished good function results. Better results may be obtained by exsection.
Many of these more serious forms of dislocation are compound. In such cases removal of the astragalus, or a more or less typical resection of the ankle-joint, may be judicious. In crushing injuries, either primary or secondary amputation may be necessary.