for Stress
inversion of the
MediCal Corps, Fort United
Carson,
or Eversion Ankle
Stales Army Reserve
Colorado
Roentgenograms
BY CAPTAIN Front ELIAS the D. SEDLIN. States United Army
Hospital,
use stress
in
ankle, discussed
diagnosis
made
in
while
acute or
applying
113
inversion an important
ligamentous
or
frequently has
The
as
establishing
chronic
of
that
the
ankle.
has
Customarily,
disadvantages.
stress
been
large
applied
number of
manually
ligamentous
obvious
injuries lated
the
sustained of a
by Army recruits at Fort Carson, Colorado, device for obtaining these roentgenograms of the stress. and use of It minimizes an the apparatus surgeons foot
eliminates the need for manual application This article describes the fabrication proved entirely satisfactory and practical. to radiation, conserves of the roentgenograms, technique.
with ease.
his time, and eliminates motion of the a frequent cause of poor roentgenograms easy
the
It is inexpensive,
In my experience,
to apply,
apparatus
and
stress
roentgenograms
were
indicated.
THE DEVICE
The
device
consists
of a foot
piece,
an
anchoring
thigh
strap,
and
two
con-
necting ropes which shop (Figs. 1 through aluminum for turret clamps; for the retaining clamps; clothesline the
two
quickly needed
connecting rods; welding rod, one-eighth of an inch in diameter, for the rings ; steel wire, three-sixteenths of an inch in diameter, for the rope one-inch webbing for the thigh strap; and approximately five feet of for the connecting rope. Fabrication of the apparatus includes rods, with shaping of the turret rope clamps. clamps and connecting The foot piece is padded the wide foot. and and bending one-half inch and two inches in inversion or neutral
follows : The is
of the foot plates, drilling of the retaining rings and thick ropes length, felt are over the attached
A buckle eighteen
to make the anchoring strap (Fig. 2). The device fits any adult foot and it can be adjusted to maintain or eversion of the foot with the ankle in dorsiflexion, plantar flexion,
chosen on
position,
the to
basis
of clinical
findings.
It of parts
is easily
applied An
as
two
so
parts
that they
of the firmly
piece the
are
the
slid
heel
together
and fore
along
part two
the
the
connecting
foot. of the
rods
elastic
and
conform
bandage
foot
and
the rods
foot
piece, the
starting turret
the
ankle. When
are on
then whether
are those
slid
medially
The
opinions
or laterally, connecting
assertions
or eversion plates
are
of the
in proper
Department
position,
of the
herein
construed
Army, I 184
THE
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BONE
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JOINT
SURGERY
DEVICE
FOR
STRESS
ixvsmox
OR
EVERSIOX
1185
foot
piece:
heel
flange;
clamping
screw;
connecting
rod:
(I
rope
clamp.
FIG.
loot
and
VOL. C
=
liiece
viewed
fr
rod.
ni ahove.
it Ii anchor
strap
attached:
(1
metaimiing
ring;
rope
clamp;
connecting
No. 7,
42-A,
OTOBEIt
1960
1186
E.
D.
SEDLIN
FIG.
FIG.
4
screw.
Fig. Vig.
3: Foot 4: Lower
piece as extremity
viewed
with device
from
below:
applied
for
turret
stress
clamp
inversion
and
clamping
roentgenogram.
piece
are
squeezed
against
the
foot,
The
amid the
screws
of the
turret
clamps
are
tight-
ened against the cominecting rods. just al)ove the knee, with the two
ropes
anchoring on either
strap is applied around the thigh the medial or lateral side, dependThe adjustment the foot in equinus
or iii neutral position
ing omi whether inversiomi or eversiomi stress is to I)e applied. length of the anterior cord allows stress to be applied with tion for the testing of the
anterior talofibular ligament
of the posifor
maintain the desired position of the slots of the rope clamps until they and mio moamid overlying
ankle as the injured
tion felt
of the hold
The the
foot
foot
can
Properly applied, the device remains imi position, take place because the curves of the flanges
was
rigidly.
amoumit
amount
needed
determined
in the
normal
and to The
in the the
ankle as the amount of stress sistance to further inversion mined quantitatively, of stress was used
and it is thought
needed felt.
ankle of stress
in
that
to assure performed
testing
comparable
conditions
throughout. Both
roentgenograms
an from
no
anteroposterior
were
and obtained.
in
or mortise view were of the measurements roentgenograms Since of the foot, the device the foot has when was
the tilt
obtained
revealed
anteroposterior the to
in several
difference
at
the
heel,
perpendicular
is naturally
in the is lying
most
appropriate supine.
part.
application of the device once proficiency in applying used to apply This stress in either is made. is accomplished
rotation bars
BONE
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A DEVICE
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iNVERSION
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Fio. 5
FIG.
6-A
Fig. 5: Stress inversion roentgenogram of a recruit, twenty-two years old, with an acute injury. Femoral-nerve and sciatic-nerve block was used. Exploration demonstrated disruption of all of the lateral ligaments of the ankle except for the posterior talofibular ligament. Fig. 6-A: Stress inversion roentgenogram of a recruit, nineteen years old, with an acute injury. Femoral-nerve and sciatic-nerve block was used. Exploration demonstrated a tear of the anterior talofibular ligament and the lateral capsule and an incomplete tear of the calcaneofibular ligament.
FIG.
6-B
roentgenogram roentgenogram
was of
FIG.
Fig. Fig.
inversion inversion
the
a
contralateral
sergeant,
ankle.
thirty-eight
Anesthesia
years old,
was
with
not
:i
used.
of
chronic
dislocating
VOL.
42-A.
ankle.
NO.
Anesthesia
1960
not
used.
The
tilt
of the
contralateral
ankle
was
nil.
7. OCTOBER
E.
D.
SEDLIN
clamps
and
then
by
having
the
With
patiemit
the foot
rotate
held
or externally, as desired. stand, the desired rotational has been too limited
will
be pro-
modification
conclusions
EXPERIENCE
WITH
THE
DEVICE
The
has acute
been injuries
used
of chronic
of twenty-five
roentgenograms
roentgenograms: congruous
corresponding
to the articular surface articular surfaces forms apices drawn. of these The
angle (Fig.
The were
were by was
used these
as reference
talar-tilt A maximum
of patients general
tion between
tilt of 14 degrees acute, contralateral the right maximum and left ankles, injuries than
found injuries.
8 degrees.
The
maximum
the
normal
subjects
was
10 degrees.
In with
talar tilt ranged from were treated by surgical 10 degrees were explored. did that
of less
exist extent
with As
6-B)
of the
found
talar-tilt
positively may be
associated misleading.
itself
a rough
15 degrees
in
has
been
accepted with
as the chronic
upper instability,
limit
of tilt who
ankle. in this
the
few
patients
were
that the findings clinical findings. is not tear of that by did this
may
I have
established.
lead to erroneous negative conclusions not seen any ankles in which a major on the basis of the clinical findings from 20 to 70 degrees when tested angle of less than collateral ligament.
the
not
collateral
demonstrate
was tilts
suspected ranging
method. Rubin and Witten feel that a talar-tilt a reliable indication of rupture of the fibular cate that approximately degrees or more. It is my cent over,
diagnostic
4 per feeling
cent that
manifest talar tilt of 15 be employed with 96 per as a clinical aid. Morewith clinical findings, acutely injured shown tears of a that the injured the greatest
accuracy, if the
while talar-tilt
error will be further minimized. In my experience, ankles with talar tilts of 15 degrees or more have at operation port ion of the fibular rollal eral ligament. Preliminarily, it appears
ankle,
source.of
which
exhibits
talar diagnostic
tilt
ranging error.
from
10 to 15 degrees,
presents
possible
THE
JOURNAL
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INVERSION
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1189
The disability
and an
for
stress in the
with onset
this
device such
1. Special
history,
quick
onset
of severe injury.
moderate
at the
injury,
of injury,
on careful
of edema
is found
ecchymosis
involved
after
questioning
severe
edema, clinical
marked instability,
marked to
3. Failure
strate at best, pathological Stress even testing view
anteroposterior,
that acute are injury very consistent of the gently
lateral,
with ankle slowly, and
and
the is an
oblique
history either uncomfortable
manually
or with
the
of this and in order to eliminate muscle and sciatic-nerve block or peroneal-nerve testing have of acute arisen ruptured collateral injuries. that I can attribute
in the complications
device.
for the repair of acutely plete tears of the lateral stress does
occurred.
ligaments, ligament
I have attempted to extend incomby application of a marked inversion In view of this experience, it the damage that has already usually in routine been associated views of the with ankle
but have been unable to do so. that stress testing will increase of the evidence deltoid of talar ligament displacement use have
little type.
collateral
SUMMARY
1
011
A practical
and
effective or eversion at minimum making of rigid to obtain exposure been used in which
been
device
is described
for
the
maintaining
of stress
while roentgenograms cost and is simple it easy fixation to store the and device
x-ray thus
compact, providing
movement
reduction
better to the on
roentgenograms. Also, the device enables surgeon or technician who would otherwise a large number acute
by use
personnel of the of
device.
both and
and chronic
ankles
has
there Accurate
were
diagnosis
collateral of of
ligaments
ankle
made
possible
acute operation
were
to the forceful
must
carried the
5. The clinical
findings findings.
roentgenograms
interpreted
REFERENCES 1. ANDERSON,
K. J.;
LECoCQ,
J. F.;
and
Ankle 34-A:
VOL. 42-A,
Cases
LECOCQ, and an
of
the
Surg.,
OCTOBER
1960
1190
E.
D.
SEDLIN
2. ANDERSON, K. J., and LEC0cQ, J. F. : Operative Treatment of Injury to the Fibular Collateral Ligament of the Ankle. J. Bone and Joint Surg., 36-A: 825-832, July 1954. 3. BONNIN, J. G.:Injuries to the Ankle. London, William Heinemann Ltd., 1950. 4. CLAYTON, M. L.; Timorr, A. W.; and UUN, ROBERT: Recurrent ubluxation of the Ankle.
With
33-A:
Special
Reference
to Peroneal-Nerve
Block as a Diagnostic
Am.
Joint
Surg.,
502-504 Apr. 1951. 5. DzIoB, J. M. : Ligamentous Injuries about the Ankle Joint. 6. KzLLY, J. H., and JAMES, J. M. : The Chronic Sublu.xating
618-621, 1956.
7. KLEIGER, BARNARD: The Diagnosis and Treatment of Traumatic Lateral Ankle Instability. New York State J. Med., 54: 2573-2577, 1954. 8. KLEIGER, BARNARD: The Mechanism of Ankle Injuries. J. Bone and Joint Surg., 38-A: 59-70, Jan. 1956. 9. MEEKISON, MURRAY: Ankle Injuries. In Reconstruction Surgery of the Extremities, The American Academy of Orthopaedic Surgeons, 1944, pp. 477-482. Ann Arbor, J. W. Edwards, 1944. 10. RUBIN, GUSTAV, and WImN, Moaius: The Talar-Tilt Anile and the Fibular Collateral Ligaments. A Method for the Determination of Talar Tilt. J. Bone and Joint Surg., 42-A: 311-326, March 1960. 11. STEELE, M. K. JR. : Diagnostic Criteria of Fibular Collateral Sprain of the Ankle. United States Armed 1orces Med. J., 6: 1752-1761, 1955. 12. STEWART, M. J. : Dislocations. In Campbells Operative Orthopaedics. Ed. 3. Vol. 1, p. 426. St. Louis, The C. V. Mosby Co., 1956.
13. WATSON-JONES, hams and Wilkins REGINALD: Fractures Co., 1955. and Joint Injuries. Ed. 4. Vol. 2. Baltimore, The Wi!-
KOaLR, ALBAN : Grenzen des Normalen und Anfange des Pathologischen im Rontgenbilde. Ed. 5. Leipsic, Georg Thieme, 1928. 19. LINGUERRI, R. : Frattura iSOlata di u.n osso del carpo (trapezio). Radiol. Med., 29: 74-75, 1942. 20. MANDL, FELIX: Em Fall von isolierter indirekter Fraktur des Os multangulum majus. Beitr. z. Klin. Chir., 123: 198-202, 1921. 21. MANON, Mi.x: Les fractures du trapeze dans lee traumatismes du poignet. Rev. dOrthop., 11: 127-140, 1924. 22. DE Moiuzs, FERNANDo: Fracture du trapeze. Rev. dOrthop., 25: 217-226, 1938. 23. MORICONI, L. : Frattura isolata del trapezio. Rass. Internaz. Clin. e Terap., 17: 843-847, 1936. 24. ODIN, OLOF: Two Cases of Fracture of the Trapezium (Os Multangulum Majus). Acta Radio!., 15: 83-86, 1934. 25. Omrro, P. : Suile fratture del trapezio. Riv. San. Siciliana, 23: 589-594, 1935. 26. PERKINS, C. W. : Fracture and Dislocation of the Proximal End of the First Metacarpal Bone and Fracture of the Trapezium. Med. Rec., 90: 539-540, 1916. 27. PfrFRIDIS, PAvios: Fracture du trapeze. Rev. dOrthop., 26: 149-151, 1939. 28. RICHARD, ANDR& and Fvius, MARCEL: Fracture du trapeze. Bull. et M#{233}m. Soc. Nat. Chir., 51: 1104-1106 1925. 29. SCHUM, H. : Weithre Erfahrungen Uber die Bruche der Hand-und Fingerknochen. Deutsche Zeitschr. f. Chir., 193: 132-139, 1925. 30. SENTI MONTAGUT, V. : El tratamiento de las fracturas de Bennet. Actas Soc. Cir. de Madrid, 5: 109-119, 1946. 31. SomumzL ETLENNE: Fracture du trapeze. Bull. et M#{233}m. Soc. Nat. Chir., 55: 1431-1433, 1929. 32. WINTERSTEIN, 0. : Die Frakturformen des Os Metacarpale. Schweizerische Med. Wochenschr., 57: 193-198, 1927. 18. DISCUSSION
DR. are rare, indirect CARRUTII JOHN
fractures
WAGNER, even
and isolated
This,
greater
multangular
usual
injury
is of an
than of a direct nature. In the usual case, there is a fracture-dislocation of the first joint. The multangular fracture is usually accompanied bya Bennett type of fracture of the first metacarpal or avulsion of the radial aspect of the second metacarpal base, or both. Isolated fractures, as indirted in the authors series, are almost invariably due to direct blows to the wrist. As in two of the authors cases, diagnosis is not always easy. The usual roentgenogram of the wrist reveal the greater multangular to be overlapped partially by the lesser multangular, navicular, and the first and second metacarpala. I have found it helpful in studying roentgenograms of rather carpometacarpal
(Continued
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THE JOURNAL OF BONE AND JOINT SURGERY