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JBXCISIOJJ or -THE ASTBAQALUS FOB INJUB,Y — KB. SQ^PBBBD. ^5
ON TWO CASES OF
Ei^CISION OF THE ASTRAGALUS FOR INJURY.
By Francis J. SBBPHinn, M.D.
Hargeon to the Sfontr«al Qeneral Hoipital.
The astragalus is not very frequently removed except in the
course of the operation of exci^/ion of the ankle or for correcting
the deformity in the severer forms of club-foot. The two cases
narrated Jbelow have many points of interest. In both, in-
jury necessitated the" operation ; in one case the traumatism
caused dislocation wii > fracture, and in the other dislocation
aflmijS. Both cases resisted all efforts at reductioQi, In c case
this was apparently d^e to the fact that the tendon of the tiki^. U»
noHticuB had in some way become tightly stretched over the outer
surface of the astragalus and thus prevented its reduction. The
case of fracture, which afterwards became compound, .esulted
from jumping off a train whilst in motion, and within the last
few years 1 have seen several cases which were due to the same
cause, though in all these cases the fracture was simple. The
patients recovered with useful feet but stitf ankle-joints, and with
some deformity. In the cases of excision the result was much
butter, and the patient could move about with more freedom and
\ess limping, although there was more shortening. In the case
9f fracture, there was also dislocation of the anterior fragn ?nt.
'J he character of the fracture was of interest. The astra^^alus
was broken into three pieces, the central portion corresponding
to the part covered by the lower articular surface of the tibia.
Thl* anterior portion was formed by the head and the posterior
hy the projectmg portion of astragalus which is grooved for the
tendon of the flexor longus hallucis muscle.
Case I — Dislocation of the Astragalus, with fracture of the
inner and outer malleoli of the ankle joint. — M. G., aged 25,
% pedlar, was admitted into hospital July lOth, 1886, with the
following history. On 27th May last fell out of a waggon and
caught left foot in wheel ; in this way twisted ankle. On being
r,eleased, found foot out of place and could not walk. Twelve
Ijours after accident, was seen by Dr. H. Stevenson of Wako,-
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MONTRSAL MEDICAL JOURNAL.
field, Que^vbo, after getting foot in position, placed it in a box
splint ; there was great fwelling. After sixteen days the foot
<was examined under chloroform and an attempt made to reduce
the displacement, but without lesult. The foot was agaii; ^)ut in
box splint, in which it remaiaed till a day or two before entrance
into hospital, when it was put up io a glue bandage.
Present condition. — Patient, a'small-sized, wiry-looking man,
was placed under ether and examined ; the foot was strongly
everted, and there was a dislocation of the astragalus down-
wards and forwards ; internal malleolus very prominent and skin
red, and a small opening over it communicating with the bare
bone ; tendo-Achillis contracted ; fibula fractured 8 inches from
lower extremity, and united at an obtuse angle ; a considerable
slough had formed on heel. After attempting, unsuccessfully, to
reduce the displacement, the tendo*Achillis was cut and another
unsuccessful attempt at reduction made. An incision was now
made from the internal malleolus forwards to the base of tli«
first metatarsal bone, ^ inches long. The joint was exposed
«nd the following condition found. The tip of the internal mal-
leolus was broken off and ununited, the astragalus was thrown
forward and separated completely from the tibia and fibula, with
the exception of the internal ligament, which was attached to
the broken portion of the internal malleolus. Lying between
the tibia and fibulft, and tightly stretched over the outer side of
the astragalus, was the tendon of the tibialis posticus muscle
(the anticus was in its plaee). This bad been one of the causes
of the failure of efforts at reduction, as the tendon held the bone
in place. The tendon was cut, but reduction was still unsuc-
cessfully attempted ; so the astrr.gblus was freed from its re-
maining ligamentous attachments and removed, also the frac-
tured portion of the internal malleolus and the end of the fibula.
The foot now came into position, and was dressed with a pad of
sublimated jute and a rectangular splint placed on outei side.
There was considerable oozing for twenty-four hours.]
A small pocket of pus formed at inner side some ten days
flfter the operation ; this was opened. The slough on the heel
gave considerable trouble ; and from that time patient went oo
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«X0IflION or THl ASTBAaALUa Voli INJUIIT — DE SIIEI'HEUD. 9*7
^ell, thou^ for some time pus continued to burrow up the leg,
iffhich bad to be freely incised. By the beginning of September
.the foot was doing well.
Early in October be oenmer.eed <te move about on crutches,
and could put his toes to the ground. He was discharged on
*0ot. 10th with all the wounds healed with the exception of an
lulcer on the heel the size of a 25oent piece.
I saw the patient in January 1887. He had a suitable boot
made, and could walk.about.and attend to his business comfort-
ably. The ulcer on the heel had completely closed. There was
iibout two inches of shortening.*
Cabb II — Dislocation with Fracture of the Left Aitragalut
•and Compound Comminuted Fracture of RiylU Tibia and
Fibula. — J. C, aged 22, brakeman, was admitted into the
Montreal General Hospital August 8th, 1886, suffering from
severe injuries ^j both legs. He gave the following account o€
ithe accident. Whilst " braking " on a freight train, which was
.going :at the rate of between 30 and 40 miles an hour, patient
"was standing on tht top of the last car ; the train swept round
a curve and threw him off his balance, so to save himself he
jumped and landed on his feet. He was pi«ked up and taken to
a doctor, who applied temporary dressings to his injured legs
:and sent him into Montreal to hospital, where he 'Came under
imy care.
On entrance his condition, -taken from the case report by the
house Burgeon, Dr. Birkett, was as follows : " Upon the right
leg, opposite the upper portion of lower third of tibia, a trans-
verse, 'irregular wound ^is seen, 2| inches long, communicating
with fractured bone. On examining still further the tibia is
found to be splintered into several pieces, whilst the fibula is
fractured about its middle third. Pulsations felt both in dorsalis
ipedis and posterior tibial arteries.^^CoBttderable amount of oozing
'from the wound. On examining the left leg it is found to be
much swollen, very painful and tender. The foot is strongly
* This patient was presAnted totbe meeting of the Canadian Medical Association,
in Mortreal, JSeptember 1891i and at that time had a most useful footi and ooaM
waUc vitfa rery slight limp.
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MONTRIAL mDIOAL JOURlfAL.
inverted and Bxed. Half an inch below and in front ot the ex-
ternal malleolus a sharp prominence of bone is felt, over which
the skin is tightly stretched. This apparently is a fractured
poition of the astragaks which u (Ksloeated outwards. The
circulation in foot is good."
The compound fracture of the tibia was treated in the usual
way with iodoform and jute pad after thorough irrigation with
1-2000 of bichloride, and, after a few days, put up in plaster-
ot-Paris, a window being left opposite the wound. The luose
pieces of bone had previously been removed, and the wound
granulated rapidly with but little sappnration, and there was
good union of the bones with about two inches shortening.
At the present time the condition of the left foot interests us
more and bears directly on the subject now engaging our atten-
tion. The patient was placed under ether and reduction of the
displaced fragments of the astragalus attempted, but without
result, so, considering the general condition of the patient and
the other injuries, no further attempt at reduction was made,
the foot being put up in a splint and kept at rest. On the 4th
of September, the general condition of the patient being favour-
able, the left foot was again examined. On removing the dress-
ings it was found that the skin over the projecting portion had
sloughed, and that the broken bone projected through an ulcer
about the size of a 25-cent piece. It was at once decided to
remove the astragalus ; so the patient being placed under ether,
an incision was made from the external malleolus downwards
and forwards for some two inches, and through this incision the
three portions into which the astragalus was broken were easily
removed. The anterior and posterior portions were quite free,
whilst the central fragioent, which corresponded to the portion
covered by the lower end of the tibia, was attached to the inner
malleolus by the internal lateral ligament, and there was no
fracture of either malleoli. The wound was stuffed with sticky
iodoform gauze and covered with a jute pad, a back splint being
applied.
The progress of the case was most satisfactory, the wound
having completely healed by November 14th and motion of foot
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PTTiaPVHAL INFECTION AND AB80ES8K8— Dn. BUTOinNSON. 99
good. Patient was going about the ward on crutches by IPth
January, and was discharged from hospital on Feb. 5th, 1887,
with good union of right leg and excellent motion of right foot,
lie walked well without a limp, the shortening (two inches) being
the same in both legs. We could not have told by his gait that
he had suffered from such a severe accident. I have heard of
him several times since, and he is gate>keeper on one of the rail-
way crossings. 1 am told that he walks without fatigue and
without any limp. In this case removal of the bone was neces-
sitated by the character of the fracture, for had the parts been
left, the anterior and posterior fragments would surely have
necrosed and led to greater tieublle. Ihe result of the case was
in every way satisfactory.
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