Volume 1

A system of surgery / Translated from the German, and accompanied with additional notes and observations, by John F. South.

Maximilian Joseph von Chelius

Date:: 1847

Credit: A system of surgery / Translated from the German, and accompanied with additional notes and observations, by John F. South. Source: Wellcome Collection.

995/1006 (page 811)

$1099. Every complete, although simple dislocation of the astragalus, is of great consequence, as its reduction is often very difficult, frequently quite impossible, and, in that case, a great degree of lameness remains ; or by the stretching of the integuments a slough is formed, which only rarely remains superficial, without opening the joint, (Dupuyrren,) but mostly after its separation lays bare the joint, in consequence of which, severe inflammation, extensive suppuration, slough, and dangerous symptoms, are produced, and even amputation may be rendered necessary ( Boyer.) Only when the dislocation of the head of the astragalus is not complete, can the function of the foot be gradually to some extent be restored, if re- duction has not been effected (DupuyTreEN, Boyer.) In compound dislo- cation the danger is still greater, and depends on the kind of complication. The impossibility of reducing dislocation of the astragalus, even by treatment accompanied with the greatest care and force, as observed by Borer, AstLEy Cooper, _ DupuyTren, myself, and others depends on the firm locking of the neck of the astra- galus between the other bones. In the dislocation inwards, the neck of the astragalus is so locked in between the inner edge of the navicular and heel-bone, that it is com- pletely immovable, or when the hinder under edge of the upper-joint surface of the astragalus lies under the front edge of the shin-bone, as DupuyTREN once observed. In dislocation outwards, the head of the astragalus may be found beneath and a little before the outer ankle, and its neck pressed on the edge of the hind-joint-surface of the heel-bone, or the head of the astragalus rests upon the cuboid and outer cuneiform bones; the outer edge of the upper-joint surface of the astragalus is placed between the first hinder-joint-surface of the heel-bone, and the shin-bone; on which account it is impossible to free the astragalus by the ordinary methods of reduction. [The simple dislocation outwards, from the cases already mentioned, may be presumed to be irreducible.—J. F.S.] 1100. The reduction of dislocated astragalus, in which it must not be forgotten to diminish the contraction of the muscles, in powerful sub- jects, by blood-letting, nawsea, and so on, always require bending the leg at the knee-joint. ‘Two assistants fix the thigh, or a folded cloth is for this purpose carried round beneath the knee, and fastened to a hook behind the patient. Other two assistants fix the leg above the ankle. A folded cloth is to be applied round the heel, carried over the instep, and crossed, without covering the projecting bone, and its ends given to assistants to make extension. The extension must be made gradually and strongly, in the direction which the foot has; the Surgeon places the fingers of both his hands upon the sole of the foot, and the thumbs upon the projection of the astragalus, which he presses back. This pressure may be practised with the flat of the hand, or whilst with the one hand he grasps the leg, and with the other the toes, he places his knee against the projecting astragalus, and thrusts it back (Perrunti.) I the reduction be effected, the leg is to be placed half-bent, upon a chaff bag, and retained by the apparatus used for fractured splint-bone, (par. 703,) in a position contrary to the direction of the dislocation. The inflam- matory symptoms are to be prevented, or got rid of, by strict rest, cold applications, and so on. 1101. If the reduction be not possible, the attempts to effect it are not to be carried too far, because thereby undoubtedly, severe inflammation and danger of gangrene will be produced ; but the astragalus must be laid bare by a semilunar incision, of which the convexity 1s directed upwards, the firmly attached parts of the ligaments divided with the knife or scissors, and the reduction then attempted ; after which the wound is to be closed with sticking plaster. If the replacement be impossible, it$