Surgery, with Special Reference to Podiatry Part 23

In the second form of subastragaloid dislocation, the astragalus is completely separated from its articulation with the bones of the leg as well as with the calcaneus and scaphoid. To this form the name total dislocation of the astragalus is given.

+True Subastragaloid Dislocations.+ These dislocations may occur in four directions, inward, outward, forward, and backward.

_Dislocation inward._ The most frequent cause is a forcible adduction of the foot combined with violence acting in the direction of the long axis of the foot. The diagnosis can be made from the position of the foot. The foot is adducted and rotated inward, as in a case of clubfoot. The sole of the foot is directed inward. The inner edge of the foot is concave and shortened while the outer edge appears lengthened. The external malleolus and head of the astragalus are very prominent on the outer side of the foot. Below and behind the inner malleolus the scaphoid projects beneath the skin.

_Dislocation Outward._ This occurs after forced adduction of the foot.

The symptoms are the opposite of those of the inward variety. The foot is in the position of a flat foot, its inner edge depressed and outer edge raised. The inner malleolus is close to the sole of the foot, and in front of it the head of the astragalus forms a prominence. The injury is not infrequently compound, so that the astragalus presents into the wound.

_Dislocation Backward._ The cause is usually a plantar flexion of the foot. The signs are very p.r.o.nounced; the head of the astragalus can be seen and felt lying upon the upper surface of the scaphoid and cuneiform bones. The anterior portion of the foot is shortened while the heel is lengthened and the tendo Achillis is very prominent.

_Dislocation Forward._ This follows forced dorsal flexion of the foot, the patient falling forward after landing with his heels upon the ground. The diagnosis can be made because of the lengthened anterior portion of the foot and the shortened heel. An important point in the diagnosis of subastragaloid dislocation is the absence of any prominence due to the projection of the body of the astragalus, in front, behind, or to either side of the malleoli, as is seen in the case of the tibiotarsal dislocations. A second diagnostic point is the abnormal position of the calcaneus and scaphoid with relation to the malleoli and astragalus. The swelling is usually so great that a diagnosis is very difficult without the use of the X-ray.

+Treatment of Subastragaloid Dislocations.+ Reduction can usually be effected in recent cases by manipulation and traction. In the inward variety the existing adduction is at first increased. Pressure is now made over the outer side of the adduction and the inner side of the foot, and the foot is then strongly abducted. In the outward variety, the abduction is first increased. Pressure is then made over the outer side of the foot until reduction is effected. In the backward variety, the plantar flexion is first increased and the foot is then strongly flexed in the opposite direction. In the forward type, forced dorsal flexion will effect reduction. The foot should be placed upon a posterior molded splint for three weeks, after which pa.s.sive motions are begun. If the reduction is impossible, an arthrotomy with excision of the astragalus may be necessary.

+Total Dislocation of the Astragalus.+ This form of dislocation is much more frequent than those of the ankle joint proper, or of the articulation between the astragalus, calcaneus, and scaphoid. The displacement of the astragalus may occur in one of six directions: forward; outward and forward; inward and forward; inward; backward, and by rotation.

The most frequent variety is the "outward and forward." In this variety the foot is rotated markedly inward and the external malleolus is very prominent. The foot is in a clubfoot position. The dislocated astragalus can be felt as an irregular angular bone just below the external malleolus.

+Treatment+ is the same as in subastragaloid dislocations.

+Dislocation of the Metatarsal Bones.+ This may be either complete or incomplete at Lisfranc's joint. It occurs most often in an upward direction. The dorsum of the foot is more convex than normal, while the sole of the foot is flattened. One can see and feel the displaced ends (upper) of the metatarsals on the dorsum of the foot. The foot is shortened and the toes point inward.

Dislocations of the individual metatarsal bones are much rarer. The middle ones are displaced upward, and the first and fifth, inward and outward respectively.

+Dislocation of the Toes.+ This occurs most often in the metatarsophalangeal joint of the great toe after forcible flexion. The dislocation may be complete or incomplete. In the former case, the proximal end of the first phalanx and the dorsum of the foot are prominent, and the head of the metatarsal bone projects on the sole of the foot. The reduction of toe dislocations presents no difficulties.

+SPRAINS+

+Definition.+ A sprain is a joint wrench due to a sudden twist or traction, the ligaments being pulled upon or lacerated and the surrounding parts being more or less damaged.

+Sprains of the Ankle.+ On account of its flexibility and constant use in weight-bearing, the ankle is the joint most frequently sprained.

Sprains are common in a limb with weak muscles; in a deformed extremity in which the muscles act in unnatural lines, and in a joint with relaxed ligaments.

A joint, once sprained, is very liable to a repet.i.tion of the damage from slight force.

+Symptoms.+ The symptoms manifested in a sprain are as follows: severe pain in the joint; nausea and sometimes syncope; impairment, or loss of motion; severe pain upon motion; early swelling if hemorrhage is severe-in any case swelling begins in a few hours; movement of the joint becomes difficult or impossible; the tear in the ligament may be distinctly felt; in a day or two pain and tenderness become intense and discoloration becomes marked.

+Diagnosis.+ Usually the diagnosis is easy to make, but in all doubtful cases an X-ray picture should be taken in order to be certain that a fracture does not exist.

+Treatment.+ The first indication is to arrest hemorrhage and to limit inflammation. For the first few hours apply pressure and an ice-bag.

Wrap the joint in absorbent cotton, wet with iced water; apply a wet gauze bandage, and put on an ice bag.

In a mild sprain, use lead and opium wash. In a severe sprain, place the extremity upon a splint and apply to the joint flannel kept wet with lead-water and laudanum, iced water, tincture of arnica or alcohol and water. If the pain is severe, a small dose of morphine should be given.

Judicious bandaging limits the swelling. When the acute symptoms begin to subside, rub stimulating liniments, such as chloroform or arnica, upon the joint once or twice a day and employ firm compression by means of a bandage of flannel or rubber. Later in the case use hot and cold douches, ma.s.sage, pa.s.sive motion and the bandage.

Another method of treatment of sprains of the ankle is by strapping with adhesive plaster, but it is advisable only for slight injuries.

In severe cases, in which extensive laceration of the ligaments is suspected from the marked extravasation, it is best to immobilize the foot in a plaster-of-Paris splint for two weeks; later baking in a hot-air oven (see "Arterial Hyperemia") with ma.s.sage, and active and pa.s.sive motion are advisable.

In simple sprains, the fixation does not produce serious stiffness, and without fixation the repair of the ligaments is only partial. In the latter case, the result is weakness of the ligaments and an instability of the foot which leads to frequent recurrence. This explains many habitual sprains. On the other hand, under appropriate treatment, a sprain should recover without leaving any functional disturbance.

CHAPTER XVII

+DEFORMITIES+

+PES PLa.n.u.s, OR FLAT FOOT+

The terms _weak foot_ and _flat foot_ will be used to designate the _mild_ and the _severe_ forms of the same condition which include all the deviations from the normal height of the arch of the foot.

+Flat Foot+ may be congenital or acquired, the former being a very infrequent deformity, and the latter one of the most common pathologic conditions.

+Congenital Flat Foot+ is a deformity of infrequent occurrence, and in some cases is a.s.sociated with defective formation of the bones of the foot. In this condition the whole foot is displaced outward in relation to the leg; the sole is rolled outward, the inner malleolus is prominent and the foot is abducted on itself, and in severe cases, it cannot be replaced in its normal position on account of the contracted tissues.

+Treatment.+ The foot should be ma.s.saged and, by gentle manipulation, forced into its proper position and held by a plaster-of-Paris dressing, changed at the proper intervals. A tenotomy may be required to bring the foot into its proper position.

When the child begins to walk, a well-fitting arch support should be worn.

+Acquired Flat Foot.+ The common form of acquired flat foot is the static variety, which is an expression of a disproportion between the body weight and the sustaining power of the muscles and ligaments.

+Common Causes.+ 1. The use of improper shoes is by all means the most frequent cause of flat foot, and frequently makes all of the following causes more p.r.o.nounced.

2. Weakness and insufficiency of the muscles, resulting from poor general condition; advancing age; convalescence from acute illness; from childbirth; and from injuries of the leg, especially fractures.

3. Prolonged standing, especially on hard wood and stone floors.

4. Rapid body growth.

5. Rapid increase in body weight.

6. Excessive weight bearing.

7. Shortened condition of the gastrocnemius muscle.

Other causes are rickets; inflammation of the ankle joint, as in tuberculosis; or, as a result of a badly treated fracture of the ankle-joint; or, as a result of paralysis of the muscles of the inner side of the leg.

+Pathology of Acquired Flat Foot.+ The pathologic condition is due to change in the relations of the bones rather than to any change in the bones themselves. The abnormal position is an exaggeration of the normal yielding of the foot under weight bearing. The front of the astragalus rotates inward, and with it the bones of the leg turn at the hip-joint.

The deformity is essentially a displacement of the astragalus on the bones of the tarsus. The scaphoid, cuneiform, and the base of the first metatarsal move downward and inward with the head of the astragalus; the outer border of the foot is made more concave and the inner border becomes convex in extreme cases. In the severest cases, the head of the astragalus, and scaphoid may be displaced below the plane of the other bones. The ligaments are respectively shortened and stretched in the severest cases and there is a loss of motion in certain of the tarsal articulations, due to faulty apposition of joint surfaces, and to constant strain.

+Symptoms.+ The feet burn and tire easily and feel stiff and lame. They may swell, and the size of the shoe worn must be then increased.

Later, a painful period generally begins in which walking is avoided and a dragging pain in the arch and behind the inner malleolus is noticed. This is increased by walking and standing and tender points may be found under the scaphoid and on the upper surface of the heel.

The foot feels strained and irritated and is a constant source of discomfort. The inner malleolus is generally more prominent and the foot is displaced outward in relation to the leg. The height of the arch is somewhat diminished; it may be much lowered, or it may be flat on the ground.