OBSTACLES

TO
BY

REDUCTION
BALDO LEITNER,

iN
M.D.,

SUBTALAR
VIENNA, AUSTRIA

DISLOCATIONS

Fronm

the

Unfallkrankenhaus,

Wien

vere

Imi the treated

twenty-five at the
dislocation, report of were

years from Unfallkrankenhaus.

of which these cases has

December
Among

1925 to the end of 1950, 449,041 these patients there were 4, 125
cent.) were recent subtalar elsewhere2.

patients cases of

traumatic A detailed The

forty-two been

(1 per published

dislocations.

cases
Medial

divided
dislocations

as follows:
:3(3 5 1

Lateral
Posterior

dislocations
dislocations

We

did

not.

observe

an

anterior

dislocation. the surgeon is above all interested in treattreatment of those dislocations in which some
reduction.

After memit. and

obstruction

ami exact. progmiosis

hinders

diagnosis of a dislocation, and particularly in the

or prevents normal closed

TABLE
SUMMARY OF

I
CASES

Type

of

Closed

Reduction Performed

Open

Reduction Performed

Total

Dislocation
Subtalar (No. of Patient.s) (No.

because
of

of
(No.

because
Concomitant

of

Dislocation Patients)

Injury of Patients)

Medial Lateral

32 5
1

3 0 0

1 0 0

36 5 1

Posterior
Total

38

42

Four
dislocation. and

of our
Three

forty-two
of these

patients
(8 per

showed
cent.)

such

an

obstruction
the talus

due
thirty-six

to the
medial

nature dislocation
joitit.

of the the dislocaof lateral an open

occurred

among

dislocations

one

(20

per
was

cent.)
due to

among
concomitant

the

five the

lateral author showed

showed

dislocations.
of the

In
at

one
the

medial
atikle

ol)struction

subluxation

Imi a review
tion, of

of the thirteen
nine

literature (8 per
(15 per lateral

was

able

to find and medial

well as the

162

cases

of medial cases had

which can be
while

cent.)
cent.)

obstruction,
obstruction.

fifty-nine dislocations
only posterior

(lislocat.ion

of which
SOII

As
reduction in the

from
five

Table
of the

I, four

of the
dislocations

thirty-six
as

all

dislocation

series were reduced by manipulation. It is worth noting that we were able to reduce omie of the lateral dislocations by B#{246}hlers method without recourse to surgery, in spite of an obstruction caused by the tendon of the tibialis posterior. In three of our four cases open reduction was necessary because of the nature of the
dislocation. navicular mentum
*

In in the cruciatum

two

of

these

open head In
Bflhler.

reduction of the fourth talus

was and case,

undertaken in

because

of

impaction

of

the

fractured cruris.
Lorenz
1954

one

because
open

of impaction
reduction was

of the

liga-

the

however,

necessary

Direktor
NO.

: Professor
2, APRIL

VOL.

36-A.

299

300 h)ecause (.11 atm acconipaimyitig sui)luxatiomi

BALDO

LEITNER

of

the

talus,

around

which

the

tendons

of the

musculi

I)emommaei
UCI1() 1! S

had

1)econie I)islocations
was

twisted.

Obstr

jim

_tI((Iial

Opemi

reductiomi 1. T..

re(luired

in

the

folloviuig

three

cases

of

our

thirty-six

medial

(hisl(

)(itt
(AS):

i Otis. I
.

oivil

servant,

was 0111(1 was

a vomiiaim, adlnitte(l

t\V(tmtV-thloe to the

y(IL)s

old.

(.)im Septenmiler thirty Clinical niinutes findings foot was

15,

1934,

slme fell

soomme I hroo nmeters

fronm

a ladder

( nfallkranken.haus Time

later. on a/mission: fully sole

immverted

right

and and
(o)Imt

somewhat posteriorly.

oiisplace(1
Time The an which time projectinmg

niedially fared
prominent.

the lateral

)alat(ral ext r(Immit.v. malleolus \V1t5 extremely 1)istal roun(l sponded the
larlv

to

it to

there

was

abnormal correhead of

j)re(ti0n talus.
over

Over both, but particuthe head of the talus, the stretched to the point of The

skin
tearing
Of

was

and

was blanched
disturbance.

as a result

the

circulatory

medial malleolus was was scarcely palpable, it there medial the was side a long of the

not visible and but distal to projection-time calcaneus-and t.ali was easily

sustentaculum

felt.. Distal
ilm(imt Fin. 1-A vas also
passive

to it. t.ii( extreniely promtui)erositv of the miavicular felt. was

were
of

Active practically
dorsiflexion

movement. impossible,

of

time foot
iltit.

and
coiiiplet.e.

fl(XiOtl
ilulse

almost

plamitar The was on a sub-

the

dorsalis

pedis findings showed

palpaijle. Roentgenographic admission: talar The breadth

inferiorly

X-ravs

dislocation foot was omme and of the

of the dislocated one-half navicular,

posteriorly

right foot. medially times as well of the as the At.by and a

by about

and
was

(Fig.
fracture

1-A).

There

also

lrocessus posterior t.ali. Treatment and progress: tempts means by wooden at closed of extension strong plant.ar wedge were
traction

reduction of the foot flexion

was

over

unsuccessful.

Following by means
O1
---,..

this,

apl)hed
appacalcaneus b means with the

of a screw-tractiomi
a clamp on the

ratus
next.

with
traction

Fin.

1-13

amid a wire of
sire

through
over in too, joint the

the met.atarsals;
leg,

iigs. I-A anol 1-B: (.ase I . Hoentgenograni amid drawing of a medial Itim(1 slight ly posteriolr suiltalar dislocatiomm. The displacement. amount.eol to aiIOUt omme an(l one-imalf tunes time width of time navicular. An obst.ruotion caused I)V time cruciate ligament, which was replaced duriimg 01)011 Ie(Iuctiolm. Timis ollstarle to reductiomm could have been overcomiie ilS a suital.Ile t.echmmique, that is, by grasping the heel amid applying mammual tract.n)n 011 time foot. with alterlmate dorsiflexion and illantar flexioim. (Fig. I-B used by permission of Ergebnisse der (hirurgie owl ()rthopMie, 37: 570, 1952.)
TilE JOURNAL

was applied
position. were was

band still

These unsuccessful. themi opened

at.-

tempts, Choparts under a long talus.

(IF

local anaesthesia incision over

by meamms of the head of the

BONE

ANI)

JOINT

SURGERY

OBSTACLES

TO

REDUCTION

IN

SUBTALAR

DISLO(ATIONS

301

Fin.

2-A

Fin.

2-B

Case 2. R.(IefltgemmOgrani and (Irawing of a niedial sui)talam (hslo(atiomm vitim inhilartiomm (It time navicular iimt.o time niedial siole of the head of time talus. Time lateral edge of the Imavi(ular had PeImttIILted sonmo three millimeters into the head of time talus. 1mmthis case the force wimich caused the (lislOratiOtm had spetmt itself in the formation of the inipactioim. It should have been possible to obtain a closed reductioim ily aim increase in the degree of adduction armd extensioim, that is, by gras)iflg the heel and applying manual t.ractioim Oii the foot. (Fig. 2-B shows a right foot, but. it was actually the left foot whicim \O5 iImV(IlVed. (Fig. 2-B used by permission of Eryehnisse der Chirurgie end Orthop#{228}die, 37: 570, 1952.) The
lage

imead

of time talus
aI)out. fifteen

lay by

inmmediately fifteen were of the was sinus was displaced

under millimeters cruciate (Fig. easily tarsi made all

the was medially crural

skin

amid it was from amid the muscle 1)assed torn The joint.

seen the

timat i)ell3

a pieoe aspect of the almd

of the extemmsor niedially with on 1)ry

time

artirular imallucis to

oartisurfaco. i)r(Vis time neck

was

nieasumiimg

missing liganient

medial iimferiorly

of time Illammtar

The was of the freely forceps.

Wit5

extensor torn. talus niovable Tile

muscles distal and was split second set The She Jindins foot ly
sligimt
015(1

of the lateral the and after was

toes linib

and drain

so prevente(1 placed day ljatiemmt was was

reduction in the a window operatioim followed oI)tained for umider

as no

1-B.
and over dressings

After
after the were

divisioum
The closure drain.

of the ligament,
ligaments skin from drain was the period inversion Out-Pat.ieimt. t.lm(
art
iVe

the head
cleamed boot.

of the
applied day gaimgreime
WRS

talus

dislocation

reduced.

were a plaster

Scissolrs

aim(I which

A
on the edge weeks. Time

of the

inimecliatelv

removed woummd.

following of twentya peri(i to tic

armd wound eight

of

removed

in and

by imifection 10 degrees 256 days observation a(t ive

of time ankle of plamitar and was for Sixteemm flexion followed a total years

The
amid no in the

of inimiull)ilization or eversiotm Departniemmt.

patieimt.

of time foot. for

patient

hospitalized therefore al,follow.-up

.

109
0i

days.

of 365 after
it)

days.
111(01 a t(n(lOtmry atmol Iassiv( in I i to
time :Ln

Clinical limB!)
miietmt
jo)iI)t
.

examiiwtion: ankle

time aoci(lelmt. t iio noutral no

t he rigimt
WILS

There

nmoveniemmt. ly
of

of time t(Ies
joiimt

posit

ion

mmiovet im( atmkle

sum tmmmor.

litmmitod.

Time

%vILs gr(at I 0) svellnmg

Ilasis omm time

t imi(kene(l. of I ime
25
,

Timeie
P:tItiulailY c(nt.

ni(Ivonl(nI

She

((Itiij)lailm((l
avardocl

of a temmdonov
conipemmsat.ion

in t lie oveniimg ankylosis of

She foot

as

per

dis:tllility. as bor
(II (V(5IOti

Roentgen.ofjraploi( iim I 0 cl(grees

fifl(lifl(JS
(If

at ,follo(1-UJ)
flexiollm.

exantirtalion

: There
110) iI)VetSi()i)

t Imo ankle

joint

Fin

j)littmtti

There

WitS

of t imo fool

Imi
without. t.ract.ioui vould wouiid
fiuially CASE ceiling (liniea,l
V(IL.
36-A,

our

opimiioui

the
vit.li

ol)sta(le
alteimiat.e

to
technique

re(luctioui
such (lotsiflexioui in this

iii

this

case

could

have an(l
(luy

ileemi

oerronie

operation at. have edge

ankylosis. 2.

l-):\ a suit.al)le foot.,

as case,
amid

grasping amid because

which led

the
plammtar of
to

heel
flexion. the

applying (hosed gamigremme

of the

matinal me(lucti(Imm of thme

atm(l

the

beemm

extuemelv set iui

clesimal)le folloviumg

vhich

operatiomi

immfection

joint.

J. E.,
He findiny.s

laborer, was on ado

1954

twenty-six to our ission:

\ears Hospital Findiimgs

old. were

()n similar

October

20, minutes

1947, later. irm Case

timis

nmaim fell 1, I)ut in

\\im(im a aol lit

ion

lourt.im-story

collapsed.

admitted

forty-five

to t imose

this

pat

ieimt

N(I.

2,

APRIl,

302

B.LLDO

LEITNER

M FIG.

3-B

Case 3. Roentgenogram and drawing off of a flake from the head of the talus. talus. In this case, in contrast to Case act.; this led to the shearing-off of the
a descrmbI 1952.) Ill Caoe

2 (Ftg

3 B u((1

of a medial suiltalar dislocation with a concomitaumt simearimigThe navicular was impacted four millimeters into the imead of the 2, the force causing the dislocation and impaction continued to flake. This dislocation could have been reduced by manipulation i) Pernimsiomm of Lrjebnise der Chzrurqie und Orthopwlze 37 570

iitd brow
teriorly,

a contusion and nose with Treatment Roentgenographic

of the and

right right findings

side on omi the

of the heel. admission: medial

thorax

and Subtalar

of the

pelvis

as

well

as left

woummds foot

amid

excoriations and of slightly the

of tb.
pos-

of the

dislocation the head of the several the i)y of of the talus.

of the talus.

niedially edge without wire seen lateral 2-B). skin was was

a depression about three progress:

side into the

of

Time were

lateral made

navicular to but effect agaimm a de-

imad pemmetrated
a closed reductiomm.

millimeters Under pin and for on the and made ether was traction

head through applied

and

anaesthesia driven was

attempts cabcaneus, means the dislocation

success passed there

A Steinmann metatarsals, Upomm exposure

a Kirschner of a screw-traction it. was

through was

time bases without

of the success.

apparatus, that edge Time

operative medial thus A drain over The for

reduction aspect prevented was the placed drain. from

Ilression three was impacted easily Lloot itml(l

(.ILs(,

millimeters in this i)\ means for first. 127 time

deep depression was was

of the head reduction in the The the drain

of the talus. The (Figs. 2-A arid sinus was tarsi (lay and after was the removed

of the navicular dislocation was The weeks healing

I)epartimieimt

reduced was split dressiimgs was Fhe l)y

of

of a gouge. woummd were applied.

closed. following Three

plaster after imi this

for

ammd a window cast. irmtentiotm.

on time day (Iperat.iofl. term weeks

Out-Patient,

operation

discormtimmued duration

second

operation

a walking patient (lays, .ti7)(li7)(JS imiovable. from swelling

of immobilization days itimd foiloweol after

was

in all.

imospit.alized a total at follaw-up Movement 65 in the received no to evening. of 162

timirt.y-five days.

ito time

it

Peri(Id

( 1110(01 weu( to pain

examination:
iii

Three
(in scar the right

years
j(Iiimt

time acri(lelmt.

timere (legrees).

was cent.

imo limmip ammd time toes Movement was in a tendency the There

freely
and

time talocalcaneal The showed examination:

reduced
65 to

by 33 per
120

ammkle joimmt. was

1 10 degrees compensation.

foot., no

from reaction.

The
talommavicular

1)ati(mmt

Roentqenoqraphic
joirmt..

jin(linf/s

at follow-up

A smmiall

degree

(If

artimrosis

was

present

in

the

In iuig the

this heel

case

it

should applying

have
manual

beemi possible
traction

to increase
at the foot

the
to

degree
overcome

of adduct.ion
the obstacle

by graspto re-

auicl

(luction
CASE

amid so effect.
3. J.

a closed
fiftv-oime

re(luctioum.
years

K.,

a laborer, imurmutes

old. 28,

This 1949.

pat.ictmt

was

buried

umm(ler

deilris

and

was

admitted

to

our

hospital

thirty

later

on

October

TILE

JOURNAL

OF

BONE

AN))

JOINT

SURGERY

0BST.LCLES Clinical liimdings

t imosoi in

10 REDUCTION

IN

SUBTALAR

DISLOCATIONS

3()3

fin(lin.(Js in this Case imad

pui)is.

on were

ado

ission:

case I , bi.it. a

siunilar

to the

in addition
of

I)tttietmt
synipimysis

sellarIttiolm

the on foot

Roentjenographic
(l(lflLiSs000

JIF)(ll nq.s revealed of a the A flake milhimetems medial Time of progress: reduction had operative failed, anaesthesia, roentgemmowitii
.

: X-ravs dislocatiotm aimd

i)V

a subrigimt. Pst.eriorlY of about had side naviculam four the millitalus of

t.alar (Figs. fourteen I)een had nieters amid

at.temi)ts local

immedially 3-A shorn

little

amid :3-B). sevemm from of the the talus.

time head

Penetrated into had Treatment

at. anaesthesia

somiie time lead impacted. and

(l(Is((l

beconme

After
under we pmoreductiomm beCase also
is ou

(ceded ummder
(RUSe of

with nitrous the

(If

OXi(Ie
timis
.

simmmilamitv
(tLse
,

grapimicallv
[hoe
. .

2. was th of dison of to ful

it . . .

II;. rm,or dugitorum reduction could location

1)iawmmmg 0)1 time

4
aImotuattIig

olllerativo

tooimimiqu(
t5(

mmmimla.m to tim it mum( recording our after thirty-six

the bocatioii,

2 It
case of
.

i)revls

iIdIt(l

(II

(11cm ib reduced

tiic

talus

d h

V c.nd

1 mmm1 90o that

time

iIcllv

aim oh is, by

of

the

tao k (us-

e-

that

in
(1.5(5

timis

alone recurred seen vas

in a case have been

of medial

sul;talar

dislocation.

Evemi

this

medial

manipulation,

i.wor-

dislocatiorm
.

redu(tmofm. niade
(ast
.

1 imis was after Time was 169 Plaster treatment

tractiomi at the foot. (Altimough the drawing simows a right foot, was actually the left foot which was mimvolved.) (tTsed 1)\ I)(rrmmissuoim of Ergebnisse der Chirurqie nail Drthop#{252}die 37 : 570 1 952. t ime disl(Irat
to timat

time x-ray t ime plaster was for were joimit Time applied. Time a period Clinical freely was patielit He navicular

ai)l)licati(Ilm

removed, was for of 240 in the

(in

ion

as
2.

reduoe followed

1 1 my Immaimil )ulat imm the there Time I)aimi at of artimrosis

(I)

an(

I fresim I)epartineuit arid

l:tst er

Furtimer patient of jindinqs movable. from felt 75

t(I

similar days.

imm Case

hospitalized total at follow-up Movement

120 degrees

sevemmtv-omme

days

alm(1 was after the 130

Out-Patieimt. was scar mmo liumip showed

days-a

examination: subtalar the on at follow-up the left. changed basis

One year
joint was

accident by :3:3 pet degrees).

time toes ankle

reduced

cemmt. ; niovemeimt t he synipimysis was

pros(lmt

in the lIubis.
imi time

foot.,
and

from
there per

65 to
was cent. A small

umo reaction.

iaimm when Jin(lings

the

weather

persistemit of disability. (legree

was joint.

awarded

compensation

of 30

J?oentgeno(Jraphi(

examination:

talom-

Iii this
tion
of of

(ase,
to as
well

iii

comitrast. act amid so

to

Case caused

2, the the

force shearing-off

which

caused of the

the flake.

dislocatioui Today, if

amid the

impacroemit.-

continued

gemiogram

the
full

mmavicular
adduct.iomi

the unsuccessful ium the damaged head

as

attempts of the

at closed reduction imidicated ammiml)actiomi talus, we should attempt reduct.ioum by means

by the of the graspitmg literature. talus had the heel.
sub-

For
talar

the
saw

sake
at

of the foot with of completemiess

should be reduction

simultamieous traction applied another obstacle to reduction

This of a (lislocation case is that takemi the from head

imma case

of medial

dislocation

memitioned.

1mm 1905 pierced

\Veuidel

operative

the extensor digitorum brevis ami(1 that the muscle hole (Fig. 4). He effected reductiomi after iticreasing
even tractioui Obstacles
Only

belly surrounded the split in the

a suitable

the mieck like a buttonmuscle. In our opinioui

such as

this at

obstacle the foot.

could

have

l)een

overcome

by

techuiique,

powerful

in

Lateral

1)islocations lateral dislocatiomis

but.

omie of oum five

was

irreducible was

at reduced

first

i)ecause

of the

positioum

of the by
VOL.

teuidon

of the

tibialis

posterior,

evemi t.his

by

the

method

deseribe(.l

Bohler.
36-A, NO. 2, APRIL 1954

304

1i.Lt)()

LEImNu:ut (.)im b)eceummi )eu I 7, nmimmut es ful1

mad

( , :SE
aimd :ts

4. .J . (
:tolmmmit I ed 1((ll hod

. ,

l:d )orem,
(1(1111

fout y-(igimt 1 bOsJIital

eams olol.
f a)t Fime

1 #{182}1.10, 1imis mmman fel I frommi a scaffolding :ts

0

t () t Imo aimt hots

I(/. On 1550)?

I %(rmtv-hve o1.

lat(I.

( Ii dist:ti at

: iime left
(Ii

evert

e( I ;umtl

lying

ag:tirmst

I lie

si( le

)f I ime t( 5)1 I igimt lv

was

1 g. I I moas
to

iisl)l:to

I lat oial lv :tim 1 post

\.ot (it ivo

of t he :ts

t:tlmms Puoi(t
(3(3

1 to omm I I
eI rent
to)

I) )i&uumm of tim ive :oul

I ic Imm((lial umE(lb(OlLls.11)0skitm at(ur)(I tlu nmm((lial ummalleolus and I 1(1)01 1(l:Lrmoim(oi.

was

t he

io:ul of I In t:mltmsvas
.

si m(t(i
()(j)iILt

umm )v(umm(rmt (If t ime t Jleolis

:ts

0(5

m(( lluoe 1 1I

:tmm I art juossoure

ummoveuim(umt,
t imere

time ankle
i(i).

lilmmit((l
in

im(lv. limelateral mmmalleolus was dorsalis

(xt nImm(lv s(rmsitive

limo I)1t15

tin

1I:tlloailh.

lto;.

5-

Ito.

-13

1. I( ((I) I gon granms ol a l:tt (ual imiferior :tImo I Ilost (10)1 I ii iahis I )Ost (di) (1 lmaoh I (((01mb imookosl ai()LIImO1 I im( t altis jim stioim (s(( ligs. 5-( :timoi 5- I ) . Flare as a rolimroummitant fraot uio of lmhnvar(h. :ts V (II :ts :t fiat rmre of t i)( J)iO((ssUs i st trioi t thi. mmmet 1)0)01. (Fime loft foo )t was :ut uahly t i)( (11)0 iimvolvool. (Figs. ii i,.o dc, io ii.,, ,(/i( ,, oil 0,/I ojmdu, 37: 557. I 952.

( ase

siml t :tl:tr oiislo(at 10)1). limo t ermo loom ( )f t ho a t hat it ,.#{149} lviimg hat (ial t ( t i)( imerk t ime latoi:tl immalleolus vimirim :ts olishllared ( hosed rooltmrl ioim ofTen ((1 1 J3#{246}imlers 5-A an I 5-13 otso I 1 v I )(iImmissio) of Rrqolo-

Im. lig.
sanme

i-(

Iuo;. 5-I)

5-(
oase.

I imat it

(ILIfl(

simoviimg t ia I )at imologioal posit ion f t Imo t rio li om 0 Of t Imo I ii i:tlis II )st(rior iii tim( limtetmoloim as (tiii((l laterally it im t im(dislorat 10)!), slipping over t imoimoaoh of tlie titlus so t (I lie hit euallv t o t lie im(ok (.)f time talus. s insemtiomm immt0 time on t he lateral 51(10 al etmol of time t ii)ia I 5- 1 ) uso.ol I )o le-

I )maviimg

Fig. 5-1 ) : I im t lme lat eial Vi(V it. s:ts 5((im t.imat. t ime t(imoloim 11:155(1 olorsallv froimm it imm((liaI ouneiforimm aimd imavicular ov(r t ime joiimt o)f I he imavioular :timd lviimg of t imo took of t im( talus. Time t (rmdonm ima(1 slilII)e(i froni its imomnial gtoovo at thmo oust :tim(l im:t I It55(( I o)v(r t he nieolial t(I t im( umterior sutface of t ime t ii lOt . ( ligs. 5-( :tim fliis5i(Iti of I.r(/(IIn iSSe dor (h ruryie 0 nil Orthop#{252}die, 37: 5139, 1 #{182}152.
THE JO)RNAI. OF BONE

ANI)

JOINT

SURGERY

OBSTACLES

TO

REDUCTION
,:.L_,.

IN

SUBTALAR

DISLOCATIONS

305

1A
V1 [ ...=---.--.Fm. 5-l I graspumg way the Fit;. 5-F Fig. 5- 1; : (lomed reolurt iou sas effected svimile t in foot sas fuII d(Irsiflcxcd. Irm frommi tim( lateral si(le (If time n(ck of time Fig. 5-I : \bim(II time foot as I)ushe(l its rmornial I)05iti0Im. (Figs. 5-E itmid 5-F 37: .19, I952.i llo(nl(/(ooo(/Iap/) tahiti
i( (If

t ime imeel atmd allplviumg tmmaumual t rart ion omm t lie foot this tendorm was freed frormi t ime obst rurt ion arid slippeh talus to time head of the boime. Imme(lially the reducti(Iim as coniI)let((l itumd I lie t(umolon regained imsed by blerniissioim of Eryebimisse (br (hiroiryoc oo,or/ 0rtIoohIoe,

,fiioilinj.s foot

on

odin

issioti

: htoeimtgcnogrammis lateral Fime PuOI(ssus

ueduot
0)11

i(vealcd were
IIOsteriOi)i

a la.teritl displaced tali uolax,

iimterioi also g(im(uitl

and

I st (nor
I

sul hat eral

,-

dislorat
7,oat,,oenl

iO)i)

t ime left

. (Out

ot im(u fouu mmmeohiallv. at t ime pittieimt rloseol

disbooatioums as

aimteuio)rly. fiart aumaest aimaest aimol at imred.

Time

mmmalleolus
fl(Xi( )i

fraot tmi(oI aimd

(110(1

displaced
:\.n

att(ummllt

mmia.le

tmimdeu Ioo:tI of t ime foot

imesin

it im full imaol I o I me I 0)

(If

I ime hip

an(l

knee,
atteimmpt

I amt , sitmee as

did

imot roIrmiIlot(ly time (lisb)lao(mmm(imt

imesia

used.
llusim

Aim unsuccessful

t imen muade

to increase

t ime saimme t inie

aimd

t ime foot niedial ruummtert racti(Iim

lv aim(I aimtei iorlv. Folboviimg iii t ime long axis of t ime leg,
of time foot., i)ut agaiim

t imis aim at temmipt as after imich Imiarmillulat

vitimout success. lie(1uotioum

Imia(le t 0) ILl #{176}I l t raot ion t 0) t he foot iomm was relleat ((I wit ii simmmult aimeous was acimieved wimemi time foot.

immV(rsio)im alm(1 eversiomm

was

plaoed irm c(.IumiI)let( dorsiflexionm I)ack dorsally. A Plaster i)O(It six weeks. Time II(riol(I obvious
I 10

amid then was apphie(l lli7.((l for

days.
(2(011)

b)Ull((l ammt(riorly amid vimicim as imniediately lays

:

Ilusim(d Imi((liitlIy, 5(1 t imitt time tcmmdon slippeol split. Time I)(rioil of immmnmoll)ihizati(Iim was I in t ime ( hit t (tm yo:trs limmsited, \Iovermient was hut
iii

blat i(Imt as I 2(5 days-a

i((ll ,IiF)(li(Of/S

hospit

fourteen

an(l he

as as limited.
).

fol loe se(n

I at ieim I I )ellart
t ime

nm(imt

Or a

of (limo

total (If 1 40 at lot/out- up Aot.ive

joint sui)talar

motiOn

\\im(n

aft er assive
time

a((iol(nmt Inovenmemmi joint

ime iotoi was froimi

an free. SO

hiflill
degrees

0mm

time left. the

mmmoveimietmt. of time to(s was alniost. 70 cimiefly

1011

ssas sligiitly Paiim

IoIovemmieimt
tO)

iii the
(iii

cormipletely to at
011

aimkle

as
irm time

right was
a%var(leoI

foot, mmoticed

froni

120 night. t he
inOti010

(legrees basis
:

Imros(nt

f)artioularIv

mmmoriming

anm(l a. t(ImoI(n(v Time Iti)(l Pat ieimt I?oentt,enotjraph I)ost(rior

to swell
vas

(olnil)eI)sa.t
(it

of 30 II(r ooimt . A sevio (h(gr(( joiumt.

of

lis:tIIihit art hrosis

v. wa s soeim in t ime :tflteriO)i

i( ,/i)i(liFU/S

.follooo-oop as vell

cram

taloralcaneal

joints

its t in. cuumeommaviculau

lum this
must

have navicular that

case, beeui

the
ab(Iut and

iumcrease
three
Simice

iii

length temidomi

of the has

course a poverful of

of

the
to

tendoum

(ause(l iumto The the

by

the
out

accident
ami aimaspect we
of must

centimeters, this cuneiform oume of

accordimig ammd gives detachment

measuremeuits iuisertion attachment

made as

tomical of the assume

cami

preparatiomi. this case

plantar well, site Part

me(lial is miot

off a fibular the

imisertioum.

imicrease

iui length
imijury

therefore

have

come

otily from imito the

from its

that

part

of the

temmdoti

proximal

to the

the tendomi was displaced (liagommally-mediolaterally--over teti(lomm which imiserted with from
2, APRIL

miormal groove at. the distal emid of the tiilia the distal end of the tibial shaft. That amid medial teuidon of the slipped navicular cuuieiform was carrie(l

amid

passed

of

the
wit Ii

miavi(ular

laterally

the dislocatiomi, It themm passed

VOL. 36-A, N(I.

the the
m954

result that. the 1)lamltar surface

laterally over the head of the talus. dorsally over t.he joimit cavity of

306 that of the of the

ill

BALDO

LEITNER

bone, distal At the tibialis

lateral

to the

neck

of the

talus,

and man

from particular tibia in

there

diagonally attentioui
was

to the paid this

medial to the tendon It

was

side course lay defione

end of the tibia. follow-up examination posterior tendon, at the however, distal that but

of this it was end the

difficult

to determine or immediately this area could

whether

its nitely

normal groove established,

of the tendon

beside it. be moved

about

millimeter, whereas in the normal person this is impossible. This may be considered proof that the tendon sheath as well as the ligamentum laciniatum had been damaged in this area, from which it is to be assumed that this ligament was torn by the lateral dislocation of the calcaneus.
REFERENCES

I . B#{246}HLER, LomtNz: 2, 5. 2. 3. 1383-1389. BALDO: im LE1TNER,

Technik Wien, Behandlung

der Wilhelm Wien

Knochenbruchbehandlung Maudrich, und sub in den tab. Jahren Deutsche 1943. Behandlungsergebnisse 1925-1950. Zeitschr.

im von

Frieden 42

und

im Fallen

Kriege, von 1905.

Aufi. Luxatio 37:

9-1

1, pedis

Band sub 1952.

frischen d. Chir. 80:

tab

Unfallkrankenhaus

Ergebn. f. Chir.,

u. Orthop.

501-577,

WENDEL:

tiber

Luxatio

pedis

251-258,

DISCUSSION Sr BPERIOSTEAL (Continued appear i)umped. inflicting

point

Gm Asp-CELL from tibial after page

Ti M(Iml 291) olecrarmon, procedures patients %%imich arc whicii, from the always being addition to is dependent subperiosteal no not has the relation the virtue do and know

with great regularity Furthermore, why trauma, of view, a constitutional

imm such do they vessels?

sites not

as the appear

shaft, pa/ella, and fractures or surgical to study giant-cell pointed its hematoma. appearance

iti

also

rupture
disturbance.

It would

be interesting

these

im(matological

to see whether
should surely be

bone

aneurysms
The terms As Dr.

present
Thompson

an unusual

response
tumor

to

trauma

which
ossifying tiIsolutely we

upon
to a

subperiosteal an organizing

and has

imematoma neoplasm.
of etiology

discarded.

out, the lesion

Although and

It
the lesion,

has

even the term misleading.

less

resemblance bone aneurysm

to

describes

behavior

of not

being
DR.

entirely

MURRAY

M.
cysts have

COPELAND, reviewed Bboodgood

phase

WASHINGTON, for
in the

D. pathology, and

C.

:
Dr.

Dr. the

Garceau natural which should and to bone We The lesion

of

and history, and

Dr.

Gregory and the early

in

discussing pointed variant

uniwhich out of

cameral arise
the existence

bone in this cysts. chips. cyst. with

of

us in the

the

complications 1930s

(OflditiOti.
an active

Dr. out

1920s

Geschickter cysts

I in the same active

development in giant-cell and age

of bone chemically we are the quiescent with clinical cancer. this The the
upon

we spoke be the the have cyst. tumor. have was

cortex,

of as a giant-cell as in giant-cell should near the then giant-cell

bone bone

We should

pointed that

that

treatment curetted

variants cauterized more cysts apt are simple tumor. bone patient
this

tumors.

Such cysts
bone
agree

be thoroughly in the in their gave complicates authors the

defect an very

be filled variant

with
of a line. I of with later. but

I feel This the

younger treatment, treatment

group because of the

frequently giant-cell lesion

the

epiphyseal the last

Dr. our
such

Thompson

an excellent

presentation

of subperiosteal course.
perforation

When seen one

which

edition of a young years

book
lesions.

was published, we had seen four patients The last patient had an interesting
had the was was surgery been usual noted this operated periosteal in the patient upon reaction, metastasis. bone did
lesion.

now

seven humerus and a half

raised

patients

in the

woman It showed whether no activity and after

who this

for thyroid but We

In

appeared

there submitted
operating

was

the

question

an atypical

to radio-active
girl, we

iodine a subperiosteal

tracer

studies, osteoclastasia

found

very

well.
THE JOURNAL (IF BONE AND JOINT SURGERY