CHAPTER XL VII.
FRACTURES OF THE LOWER ENDS OF THE TIBIA AND FIBULA.
Surgical Anatomy. — The surgical anatomy of the lower ends of the tibia and fibula is similar to that already given under the head- ing of "Pott's fracture" on page 659.
Symptoms. — "When both bones are fractured above the ankle, pain, loss of function, crepitus, abnormal mobility and swelling are usually present and well marked. The traumatic reaction is often less pronounced than that accompanying the usual fracture of the
Fig.
Fig. Fig.
749.- 750.-
-Splittiug of lower end. of tibia. -Splitting of lower end of tibia.
shaft and the mobility is, as a rule, not so completely flail-like. The line of fracture in the lower end of the tibia is quite variable and accordingly the deformity is not characteristic. The frac- ture may be transverse, spiral, comminuted or longitudinal. Longi-
675
676
FRACTURES AND DISLOCATIONS
Fig. 751.
Fig. 752.
Fig. 753.
Fig. 751. — Fracture of tip of internal malleolus.
Fig, 752. — Fracture of internal malleolus at higher level.
Fig. 753. — Fracture of internal malleolus at still higgler level.
Fig. 754. — Epiphyseal separation of lower end of tibia complicated by fracture of tibial diaphysis. Also fracture of fibula. The result of violence similar to that pro- ducing Pott's fracture.
FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA
677
tndinal splitting* of the lower end of tlie tibia entering the joint cavity is not at all uncommon and is usually accompanied by trans- verse thickening of the ankle. The line of fracture may extend from the inner surface of the bone into the joint cavity so that the inner malleolus is displaced inward or it may extend from the outer surface of the bone into the articulation and allow the frag-
Fig. 755.
Figs. 755 and 756. — Fracture of both bones of the leg just above the ankk indicate the levels of the two fractures.
ment and lower end of the fibula to be displaced outward. Diastasis of the lower tibio-fibular articulation with separation of the lower ends of the bones of the leg is occasionally seen and has been classi- fied as a complication of upward dislocation of the ankle when the astragalus is displaced upward between the ends of the bones. Supra-malleolar fracture of the tibia is usually accompanied by fracture of the lower end of ' the fibula. Fracture of the inner
678
FRACTURES AND DISLOCATIONS
malleolus usually occurs as a part of Pott's fracture, but even as an isolated injury it is not uncommon. Various types of fracture of the lower ends of the tibia and fibula occur as complications of dislocations of the ankle and of Pott's fracture, but will not be considered under this heading. It is not at all uncommon to see one of the tibial fragments projecting through the skin. The de-
Fig. 757.
Fig. 758.
Figs. 757 and 758. — Supramalleolar fracture of both bones -with inward displace- ment of the foot. Compare the two ankles. Arrows indicate the levels of the two frac- tures.
formity may be pronounced and in cases resulting from direct vio- lence the fragments may remain in the position in which they were driven at the time of the accident. Fracture of the lower end of the fibula is often attended by remarkably slight loss of function especially if the line of fracture is into the lower tibio-fibular ar- ticulation. The patient may be able to walk with such a fracture although use of the member entails pain.
FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA
679
Diagnosis. — There should, as a rule, be little difficulty in recog- nizing fractures in this region but the details of the break are often difficult or impossible to recognize without the aid of the
Figs. 759 and 760. — Fracture of both bones of the leg just above the ankle with pronounced inward displacement of the foot. The photographs were taken about twenty minutes following injury and show an unvisual displacement. /. indicates the upper end of the lower fragment of the fibula. //. indicates the displaced external malleolus. III. indicates the internal malleolus. Injury the result of direct violence.
X-ray. Fracture of the fibula may be mistaken for a sprain unless the examination is carefully made. When the fracture is supra- malleolar the two malleoli will remain in proper relation to each other but will move with the foot and not the leg. When the frac-
680
FRACTURES AND DISLOCATIONS
ture enters the joint cavity it will usually be possible to elicit ab- normal mobility of one of the malleoli (the one detached). The symptoms in separation of the lower epiphyses are practically the same as in fractures of this region except for the crepitus which is
Fig. 761.
Fig. 762.
Figs. 761 and 762. — Splitting of the lower end of the tibia with broadening of. the ankle. Both malleoli prominent. Type of case requiring operation to secure the best results.
cartilaginous and not bony. If the fracture in the fibula is above the lower tibio-fibular ligaments pressure in the middle of the shaft will produce pain at the seat of the fracture. If the fracture is through the ligaments or below them direct pressure at the site
FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA
681
of the lesion will be necessary to produce pain. AVlien the fibula alone is fractured there is usuall}^ little loss of strength in the ankle.
Treatment. — In fracture of both bones above the ankle or in epiphyseal separations the indications in treatment are similar to those cases just described in which the fracture is at the usual site (the junction of the middle and lower thirds of the shafts). The necessity for temporary treatment is not as great in this region since the traumatic reaction is seldom as severe as in fracture of the shafts. It is best, however, to place the leg in a fracture-box or pillow splint for the first few days, until the amount of swelling to follow can be determined. During this time the ice cap locally and intermittently applied is of great value. A plaster stirrup as
Fig. 763. — Old case of fracture of both bones of the leg above the malleoli. Patient presents himself for treatment because of inability to use limb. Pen outline on skin indicates palpation of fibula. This case is a good example of delayed restoration of function due to incomplete reduction of fragments.
already described in "Fractures of the Shaft" will in most cases be found thoroughly efficient in maintaining reduction. A quick drying plaster should be used and the surgeon should hold the ankle in reduction, while the splint is setting. The best position for the ankle, in a given case, is the one in which the tendency to recurrence of deformity is least. It is preferable to fix the foot in a position of slight plantar flexion rather than at a right angle. The proper position for the foot, aside from the prevention of deformity, is one in which the flexor and extensor muscles are at an equal tension and balance each other. In instances in which the lower end of the tibia is split longitudinally it will often be
682 FRACTURES AND DISLOCATIONS
necessary to force the fragments together, by lateral pressure, while the plaster is drying, in order that union maj^ not take place with transverse thickening of the ankle and widening of the mortise. If the posterior portion of the articular surface of the tibia is broken off the foot should be more or less dorsally flexed to favor reduction and prevent recurrence. When a fragment is broken off of the articular surface anteriorly the foot should be immobilized in the opposite position for the same reasons. The foot should be covered with a layer or two of sheet cotton before the stirrup is applied. The bony prominences about the ankle are subcutaneous and if the splint is not properly padded undue pressure may pro- duce sloughing of the skin. Fracture of the fibula alone does not require as solid immobilization as is the case in isolated fracture of the lower end of the tibia or when both bones are broken.
When an outward displacement of the external malleolus exists as a result of fracture of the fibula, whether the break is above, below or through the lower tibio-fibular ligaments, the deformity should be corrected and held in position by the dressing. Strong adduction of the ankle, as in the treatment of Pott's fracture, will usually correct this displacement if the internal malleolus is intact.
Operative Treatment.^ — Open treatment is not as frequently indicated in fractures of the lower ends of the tibia as it is when the shafts of these bones are broken. It is most commonly called for when there is a longitudinal splitting of the lower end of the tibia in which difficulty is experienced in approximating the frag- ments. Even a slight spreading of the malleoli means a widening of the mortise in which the trochlear surface of the astragalus rests and this condition, if not corrected, is followed by a pro- tracted recovery if not permanent disability. If two longitudinal incisions are made, one on the inner and the other on the outer aspect of the lower part of the leg, the fragments can be replaced by direct manipulation and transverse holes drilled through the approximated fragments at the most advantageous points. Heavy wire is then threaded through these holes and the ends securely twisted to maintain propel* reduction. In some instances passing wire around the fragments may be all that is required but this point can seldom be determined until the fragments are exposed. In supra-malleolar fractures open incision may be necessary to effect reduction but it is seldom necessary to employ internal fixation.
FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA 683
After- Treatment. — If the traumatic reaction is great the leg should be treated ou a pillow splint or in the fracture-box during the first few days. The swelling is usually less than that seen when the fracture is higher, and it will seldom be necessary to wait more than four or five days before placing the leg in a permanent splint. As previously stated, the plaster stirrup is the most efficient form of permanent dressing in which to treat fractures in this region. Union may be expected in the healthy adult in six weeks but the callus is not sufficiently strong at this time to permit of weight bearing. iMassage and gentle passive motion should be instituted at the end of the second week. During the eighth and ninth weeks weight bearing should be gradually increased until the patient is able to walk at the end of two and a half months. The time should be prolonged in cases in which the fracture involves the articular surfaces and when passive motion is employed due regard should be had for the tendency to displacement, if such exists. It is best for the patient to walk with a cane for some time following the removal of all dressings. Persistent swelling of the ankle should be met with massage and hot applications and, if pronounced, great relief may be had by the use of an elastic stocking during the day. Isolated fracture of the fibula without displacement may, as a rule, begin weight bearing at the end of three or four weeks.
Prognosis. — The more accurate the reduction the more complete and prompt is recovery. Some limitation of motion in the ankle, especially dorsal flexion, is common, following fractures in this region, particularly so when the line of fracture involves the ar- ticular surface. Fractures of the fibula alone are usually followed by complete restoration of function. The prognosis in other re- spects is similar to that already given in "Fractures of the Shafts of the Bones of the Leg," page 657.