90° on its antero-posterior axis, the trochlea being in contact with the cartilaginous surface of the external malleolus. The inner upper angle of the trochlea fitted closely into the reëntrant angle formed by the external malleolus and the tibia. The bone was not at all displaced forward-that is, it did not protrude abnormally from its socket. The interosseous ligament had been ruptured; the few remaining fibres were divided, and the bone removed. Examination of the cavity failed to show any fracture or detachment of cartilage. The patient made a good recovery, and was discharged nine and a half weeks after the operation.

Treatment of total dislocations of the astragalus.

The statistics, collected by Broca, Dubreuil, and Poinsot, show that of 121 cases of dislocations not compound, 43 were successfully reduced, and it is worthy of note that Poinsot's list, composed of cases reported between 1864 and 1883, shows 19 reductions in 31 cases, about 60 per cent., and as many of Broca's cases were treated without the aid of anesthesia it may reasonably be hoped that Poinsot's percentage is an indication of the success that will be obtained in future. Primary extirpation of the astragalus was done in 9 of the 121 cases, with 6 successes, 1 death, and 2 deaths after secondary amputation. Consecutive extirpation was done in 41 cases, with 39 successes, and 2 deaths. Of 15 cases in which the dislocation remained unreduced, and in which the result is known (excluding those of secondary extirpation) the functional result in 8 was good.

Of 63 compound dislocations, collected by Broca, reduction was made in 9, and of these 9, 6 recovered, secondary removal of the astragalus was done in 2, and 1 died. Poinsot adds 2 cases in which reduction was made; 1 was successful, in the other extirpation became necessary.

In 58 compound cases primary removal of the astragalus was done, with 42 successes, 14 deaths, and 2 consecutive amputations followed by death.

For reasons that have been already given, we have the right to expect better results in the future in compound cases, and may feel encouraged. to make reduction whenever it is possible. Expectation in irreducible compound dislocations has almost always ended in removal of the astragalus, or amputation, or death, and the cases will probably be very few in which primary removal of the astragalus will not give the patient the most speedy recovery, the least risk, and the most useful limb.

Of 56 simple irreducible dislocations contained in these statistics, suppuration of the joint and sloughing of the skin followed in at least 41, and there is not much reason to suppose that the frequency of this result will be much, if at all, diminished in the future, for the exciting causebruising, pressure, and destruction of the blood-supply of the astragaluswill be repeated. It is important, therefore, to determine the proper course to be pursued under such circumstances. In 1884 Dr. McBurney, of New York, successfully reduced a dislocation forward and inward by exposing the head of the astragalus through an incision, and lifting the tendon of the tibialis anticus which tightly embraced the neck of the bone and had prevented reduction; probably other equally good results will be obtained by the same means. Primary removal of the astragalus is

recommended by Barwell in all cases in which "certain and sufficient, but not too persevering, attempts at reduction" have failed, and the facts that four-fifths of the cases left to themselves have ended in suppuration and secondary removal of the astragalus, and that the functional result after removal is good, will be generally accepted as a justification of the advice, but it needs, I think, to be conditioned upon the failure of reduction by arthrotomy.

In a case of dislocation forward and outward Anger' reduced by making continuous traction by means of India-rubber for ten or fifteen minutes, and then pressing directly upon the bone. The rubber was attached to the foot by means of long strips of adhesive plaster passed in figure-of-8 around the heel and dorsum to form a loop beneath the sole to which the rubber cords were fastened.

In short, the plan to be pursued in simple cases is to attempt reduction by traction upon the foot with the hands or pulleys, under anæsthesia, and with the knee flexed, and by direct pressure so applied as first to correct such rotation of the bone as may exist, and then to force it back into place. This failing, expose the bone by incision, and seek to remove the obstacle to reduction and then to reduce; this also failing, remove the astragalus. In cases in which the astragalus is not only dislocated but also broken, I think primary removal is the safest plan, even in cases of backward dislocation of the posterior fragment, although in three such treated without removal the patients recovered with useful limbs.

In compound dislocations reduction is to be sought unless the astragalus is entirely detached or the lacerations are so extensive that suppuration is unavoidable; otherwise, primary removal of the astragalus, or amputation if clearly indicated.

4. MEDIO-TARSAL DISLOCATIONS.

In this the dislocation takes place in the medio-tarsal joint, the scaphoid and cuboid being together displaced from the astragalus and calcaneum which preserve their relations to each other and to the bones of the leg. Broca, in the paper above quoted, pointed out that most dislocations previously reported under this title were actually sub-astragaloid. Partial dislocation of the cuboid from the calcaneum appears to be frequently associated with sub-astragaloid dislocations, but the cases in which the medio-tarsal joint alone is involved are few. Cases, too briefly described to be positively accepted, were reported by J. L. Petit, Liston, and Cooper, but more recently three cases have been placed on record in two of which the diagnosis was confirmed at the autopsy. Thomas' reported a case in the service of Denonvilliers; the patient's foot had been crushed by the wheel of a cart. The plantar surface was convex, the dorsum so swollen that the bones could not be felt; the foot was shortened, and its anterior portion could be moved laterally, but the movements were painful and accompanied by crepitation. The diagnosis of fracture of the head

1 Th. Anger: Bull. de la Soc. de Chirurgie, 1875, vol. i. p. 219.

2 Thomas: Mém. de la Soc. Méd. d'Indre et Loire, 1887, quoted by Duplay and Delorme.

or neck of the astragalus and rupture of the calcaneo-cuboid ligaments was made. The patient died of erysipelas, and at the autopsy the tibiotarsal and calcaneo-astragaloid joints were found intact; the head of the astragalus and the cuboid surface of the calcaneum formed a very marked abnormal prominence above the second row of the tarsus; the scaphoid was fractured antero-posteriorly, and its outer fragment projected on the plantar surface; the cuboid was still in contact with the inferior half of the anterior end of the calcaneum; the superior medio-tarsal ligaments were ruptured, and the inferior calcaneo-scaphoid partly detached; the inferior calcaneo-cuboid was unbroken.

Anger's' patient was injured by a fall from a height. There was slight flattening of the arch of the foot, without deviation, and with considerable ecchymotic and inflammatory swelling. He died of erysipelas. At the autopsy the head of the astragalus was found above and in front of the scaphoid, and the cuboid facet of the calcaneum upon the upper surface of the cuboid. The superior calcaneo-scaphoid and internal calcaneocuboid ligaments were ruptured and torn from their anterior insertions. It was difficult to reduce the dislocation even after dissection. The only fracture was of the anterior part of the scaphoid, the tubercle of which was almost entirely torn away.

In the third case, Ward, the dislocation was old. "The foot presented a remarkably twisted appearance, the anterior part being directed considerably inward, and the inner edge somewhat elevated." The dorsum was shortened one inch. The anterior ends of the calcaneum and astragalus projected distinctly on the dorsum. The external malleolus had been fractured.

CONGENITAL DISLOCATIONS OF THE ANKLE-JOINT.

Kraske exhibited at the Ninth Congress of the German Surgical Society two patients, father and son, with congenital dislocation of both. ankles, and also the two legs of another child of the same father which had died in infancy and had been similarly affected. The abnormality was a subluxation outward accompanied by, and probably due to, defective development of the fibula. In all three cases the middle and upper part of the fibula was lacking, but in the specimen a small upper epiphysis existed. In the father the lower end of the fibula was only four centimetres long and was obliquely placed, the apex directed outward. The articular surface of the tibia was also oblique, looking downward and outward; the foot was flattened, markedly abducted, and moderately pronated. The legs, compared with the thighs, were abnormally short and slight.

Resection of both ankles had been done upon the son to correct the faulty position of the foot: on the right side the internal malleolus and a comparatively large part of the astragalus had been removed; on the left, the entire lower end of the tibia and a small piece of the astragalus. Other forms of congenital subluxation belong to the subject of clubfoot.

1 B. Anger: Traité iconographique, p. 334.

2 Waid: Trans. Path. Soc. of London, 1849-50, p. 254.

3 Kraske: Beilage zum Centralblatt für Chir., 1882, No. 29, p. 85.

CHAPTER XXXII.

DISLOCATIONS OF THE TARSAL AND METATARSAL BONES
AND OF THE TOES.

In addition to the dislocations described in the preceding chapter, the bones of the tarsus may be dislocated separately and in various combinations. None of the different kinds has occurred with sufficient frequency to permit systematic grouping and description, and in most of them the exact nature of the injury cannot be said to have been positively established, for the difficulties of the diagnosis upon the living are usually very great and the surgeon is limited to the recognition of the more prominent features. I shall confine the account of them mainly to the enumeration of the different varieties that have been observed, with bibliographical references for the convenience of those who may desire to examine the reports in detail.

Calcaneum. Malgaigne quotes a case in which the calcaneum was bodily displaced to the outer side, but apparently was not entirely separated from the astragalus and scaphoid. Reduction was easy. Also a second (Canton, Lancet, 1847, i. p. 505) found upon the cadaver, in which the calcaneum was displaced to the outer side together with the external malleolus; its anterior end lay between the cuboid and scaphoid, almost in contact with the third cuneiform; and the astragalus was rotated inward about 45°.

Scaphoid.-The scaphoid has been dislocated forward and outward in connection with the astragalus, the dislocation being compound (Burnett), forward and inward (Rizzoli, quoted by Poinsot), upward and backward in conjunction with the first and second cuneiforms and the first two metatarsals and with dislocation of the third metatarsal and fracture of the cuboid (Chassaignac, Bull. de la Soc. de Chir., 1861, vol. i. p. 307), upward and inward in conjunction with the first cuneiform (Lonsdale, Lancet, 1857, ii. p. 192) or with the middle cuneiform (Clarke, London Med. Times, 1851, vol. 3, p. 233), or outward, upward, or inward alone (Piédagnel, Walker, R. W. Smith, quoted by Malgaigne, Bryant, Surg., 3d Am. ed., 1881, p. 813), or from the cuneiforms only, as seen by Garland (Lancet, 1857, ii. p. 270) in a case that was compound. In a case reported by Enos (N. Y. Journ. of Med., 1857, II. p. 98) the cuneiform bones and the cuboid were displaced outward from the scaphoid and calcaneum.

Cuboid. The only case of dislocation of the cuboid of which I have knowledge, except in connection with other dislocations as above described, is one reported by Bell (N. Y. Journ. of Med., 1859, vol. 7, p. 329) in which it was displaced upward in connection with the fifth metatarsal by inversion and adduction of the foot. Reduction was made.

Cuneiform bones.-All three cuneiform bones and the second and third have been displaced together, and the first and second have been displaced separately. Isolated dislocations of the first are the most frequent, Lemoine collected eleven such cases, to which may be added two observed by Bryant (loc. cit., p. 813); the displacement is usually upward and inward, in only one case downward and inward (Fitzgibbon, Dublin Journ. Med. Sci., 1877, ii. p. 271); sometimes the bone is displaced from all the three with which it is normally in contact, sometimes the first metatarsal is displaced with it. The symptoms are flattening of the arch of the foot, prominence of the displaced bone, and a depression at its normal site. In some cases reduction has been easily made; in others the attempt has failed.

The second cuneiform has been separately dislocated upon the dorsum in three cases, Foulker (Lancet, 1856, ii. p. 283), Laugier, and Lagarde (quoted by Delorme, Dict. de Méd. et Chir. prat., vol. 27, art. Pied), the displacement being slight in one and nearly complete in the others, and accompanied in one by other serious injuries of the foot, and followed in another (Foulker) by sloughing of the skin, grave symptoms, and ultimate recovery. In a case of multiple injuries of the foot reported by Lagrange (Bull. de la Soc. Anatomique, 1871, p. 180) the second cuneiform was displaced upward from all its connections except that with the scaphoid.

The second and third cuneiforms were displaced together upon the dorsum in a case reported by Key (quoted by Malgaigne); the dislocation, which was incomplete, was caused by direct violence and accompanied by extensive laceration of the skin. The patient died.

All three cuneiforms have been reported displaced together upon the dorsum in several cases, but it does not appear in the histories whether or not they were separated only from the scaphoid or also from the cuboid and metatarsals; in one of them (Bertherand, Bull. de la Soc. de Chir., 1856-57, vol. 7, p. 361) they were accompanied by the metatarsals and the dislocation could not be reduced.

DISLOCATION OF THE METATARSAL BONES FROM THE TARSUS

AND FROM ONE ANOTHER.

Malgaigne collected twenty-one cases of the various dislocations, and Hitzig collected twenty-nine.

The first metatarsal is much more frequently dislocated than the others, and the displacement appears always to have been upward except in one case (Demarquay, Bull. de la Soc. de Chir., 1870, vol. 10, p. 35) in which the base lay under that of the second metatarsal; in this latter the first metatarso-phalangeal joint was also dislocated, compound, and Demarquay removed the bone. A frequent cause has been a fall while on a horse, the pressure of the stirrup against the inner and under surface of the bone apparently causing the injury. The symptoms frequently indicate the coexistence of a sprain of neighboring joints. Reduction has always been easy by traction and direct pressure.