AOT Foot Art Myths book sample

Stefan Rammelt | Hans Zwipp

The Foot—Arts, Myths, and Secrets

With dozens of illustrations and images created just for this publication, and compiled by surgeons involved with the Dresden AO Foot and Ankle Courses held annually since 2002, this book will inform and entertain all trauma surgeons specializing in foot and ankle surgery. It is specifically dedicated to all AO Faculty, who devote their time and inspiration to continuous education and networking among trauma and orthopedic surgeons worldwide.

Fibula Tibia Intermedium

Tibiale 6 Centralia

Fibulare

7 Tarsalia

ISBN: 978-3-905363-11-1

www.aotrauma.org

The Foot—Arts, Myths, and Secrets

The Foot—Arts, Myths, and Secrets covers aspects at the fringes of foot and ankle surgery, providing interesting and light-hearted reading on the historical and cultural importance of the foot in literature, art, and science. Compiled by some of Europe‘s leading orthopedic surgeons, the book includes a fascinating look at the history of foot and ankle surgery, the signs and symbols about the foot brought to life in art and literature, and the great mythological tales and tragedies created in the foot‘s honor.

Stefan Rammelt | Hans Zwipp

The human foot is a unique and delicate structure. It is the youngest part of our skeleton, the one that literally lets us stand out among the animals. It has inspired artists of all ages and continents and has given rise to countless tales and myths over the centuries.

Stefan Rammelt | Hans Zwipp

The Foot Arts, Myths, and Secrets

Table of contents Preface

III

Contributors

IV

1 The importance of the foot in language and symbolism: synonyms, eponyms, myths, aphorisms, and symbols Hans Zwipp

2

3

1

Introduction

4

2

The foot in language

5

3

Foot in synonyms, eponyms, aphorisms, allegories, proverbs

7

3.1

Eponyms

9

3.2

Aphorisms, sentences, and proverbs

4

The foot in symbolism

11

4.1

Foot symbols in writing

11

4.2

Foot as a symbol of life, freedom, and pars pro toto

11

4.3

Foot and its relationship to earth

12

4.4

Foot as a symbol of power and subjection

13

4.5

Foot as a symbol of respect, reverence, and subservience

13

4.6

Feet washing and anointing as a symbol of humility and an act of love

13

4.7

Foot as a symbol of an erotic, sexual part of the body, and fertility

14

5

The foot in psychology, body language, and social life

A short history of ankle fractures

Jan Bartoní ček

10

17 21

1

Introduction

22

2

Historical periods

23

2.1

Clinical-anatomical period

23

2.2

Beginnings of radiology

24

3

Development of radiological classifications

26

3.1

Chaput classification

26

3.2

Destot classification

26

3.3

Tanton classification

26

3.4

Lane contribution

28

3.5

Ashhurst-Bromer classification

29

3.6

Henderson classification

29

3.7

Danis classification

30

V

2

3

VI

A short history of ankle fractures (cont)

Jan Bartoní ček

4

Posterior fragment of distal tibia

31

4.1

The first description

31

4.2

Volkmann’s triangle

31

4.2.1

Posterior malleolus

32

4.2.2

Cotton fracture

32

4.2.3

Classification

34

4.2.4

Operative treatment

34

5

Beginnings of operative treatment

35

6

Conclusion

38

Artistic anatomy of the foot

43

Patrick Cronier

1

Introduction

44

2

History

45

3

Morphology

49

3.1

Ankle and hindfoot

49

3.2

General foot morphology

52

3.3

Muscles and tendons

54

3.4

Toe formula

56

3.5 Toe direction

58

3.6

Veins

62

4

Conclusion

63

4

Oedipus Tyrannos—King Oedipus, a foot story

5

From prehistory to judgement day: accessory bones and sesamoids of the foot

65

Kaj Klaue Stefan Rammelt

79

1

Introduction

80

2

Milestones in the evolution of the hindlimbs

81

3

Prehistoric roots of accessory bones

87

4

More recent etiologies of accessory bones

90

4.1

Os tibiale externum (accessory navicular)

4.2

Os naviculare bipartitum

92

4.3

Os trigonum

93

4.4

Talus bipartitus

94

5

Constant and inconstant sesamoids at the foot

95

6

An outlook on judgement day

98

91

The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

A short history of ankle fractures

Jan Bartoní ček

21

2 A short history of ankle fractures

1 Introduction Ankle fractures still remain a significant issue in bone and joint trauma surgery that has not yet been adequately resolved. The history of treatment of these fractures is interesting and it is no wonder that it has been the subject of many studies [1–8].

The first detailed historical overview was published by Astley Paston Cooper Ashhurst (1876–1932) in 1922 [1]. This valuable resource was most probably used by Niels Lauge (later known as Lauge-Hansen) (1899–1973) in 1948 [5] and also by Josiah Grant Bonnin (1909–1989) in 1950 [8]. Lauge’s treatise was the most detailed historical study at that time to focus on ankle fractures, a large part of which was later used by Bernhard Georg Weber (1927–2002) in his book “Die Verletzungen des oberen Sprunggelenkes” [9].

Although it may seem that there is nothing to add to this mosaic of historical study, it is not quite true. The facts presented are not always accurate and differences of interpretation may also be found. Depending on each author’s perspective, certain information may have been highlighted or alternatively neglected. Now and then a newly traced fragment of information may be added to the mix [2–4, 7] and thereby present a modified view of the history of ankle fractures.

This current historical review focuses on several aspects of the history of posterior malleolar fractures, including the role of radiology, classifications of these fractures, and their operative treatment.

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The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

2 Historical periods Jean Tanton (1885–1918) in 1916 [10] divided the history of ankle fractures into three periods, ie, clinical, experimental, and radiological. This schema was adopted by Lauge [5] in 1948. Weber [9] presented in 1966 an extended concept of five periods: clinical, experimental, radiological-clinical, conservative-genetic, and surgical. Bonnin [8] published his own historical division in 1950. All these attempts were somewhat artificial, as individual periods actually overlap or run parallel, and, therefore, cannot be strictly distinguished one from another.

“

A watershed in the history of diagnosis and treatment of ankle fractures was the discovery of x-ray imaging.

A watershed in the history of diagnosis and treatment of ankle fractures was the discovery of x-ray imaging. The invention of anesthesia and antisepsis brought substantial change to the treatment of several types of fractures, such as patellar or forearm fractures, although not ankle fractures. The history of the treatment of ankle fractures may be divided into two main periods, ie, clinical-anatomical (preradiological) and radiological, the latter being closely associated with the beginnings of surgical treatment.

2.1

”

Clinical-anatomical period

The onset of the modern era of ankle fracture treatment is marked by the study published by Percival Pott (1714–1788) who in 1768 [5, 8] described an ankle fracture (including a drawing), which later bore his name. He was followed by a number of prominent authors, predominantly from the ranks of the French surgeons, ie, Boyer, Dupuytren, Cooper, Earle, Adams, Maisonneuve, Bonnet, Malgaigne, Huguier, Tillaux, and Hönigschmied [1, 5, 8]. This period ended with

Fig 2-1 Drawings from Hönigschmied´s experimental study [11].

23

2 A short history of ankle fractures

discovery of x-rays in 1895. Details of this period may be found in the article published by Lauge [5], and also in the Bonnin’s textbook [8]. The sources of knowledge during the clinical-anatomical period were primarily thorough clinical examination and also autopsy reports. Many patients with ankle fractures died of the consequences of this injury. This concerned mainly open fractures, where amputation was indicated as the method of choice, and closed fractures with gangrene developing probably as a result of the then unknown compartment syndrome.

The first half of the 19th century was a period of experimental anatomical studies on human anatomical specimens. A pioneer in this field was Guillaume Dupuytren (1777–1835), pupil of Alexis Boyer (1757–1833), who conducted such a study around 1816 [8]. The best known are the experiments made by Jacques Gilles Maisonneuve (1809–1897), published in 1840, who was followed by Amédée Bonnet (1809–1858) in 1845, by Pierre Charles Huguier (1804–1873) in 1848, by Paul Jules Tillaux (1834–1904) in 1872, and by others [5, 8]. All these efforts culminated in the study by Johann Hönigschmied (1843–1895), conducted in 1877 [11] on 125 human anatomical specimens (Fig 2-1) that was commented on by Bonnin [8]: “Since this time much experimental work has been done, culminating in the teutonically thorough work of Hönigschmied…”

All the above-mentioned authors studied the effect of the injury mechanism (abduction, adduction, external rotation) on both the anatomy of the fracture and sequence of individual lesions, although not always with consistent outcomes.

The relevance of such experiments was questioned by Joseph François Malgaigne (1806–1865), who in 1847 [12] published the first complete volume on fractures with beautiful copper-plate engravings of anatomical specimens of ankle fractures (Fig 2-2). In his view ankle fractures were regarded as rare.

“

Malgaigne published in 1847 [12] the first complete volume on fractures with beautiful copper-plate engravings of anatomical specimens of ankle fractures.

”

Joseph François Malgaigne (1806–1865).

The representatives of the clinical-anatomical period largely contributed to further development in this field by presenting a detailed description of clinical symptoms, laying down foundations of experimental surgery of the ankle that continued throughout the entire 20th century, and by specifying individual fracture patterns and injuries to various ankle structures, all instructively illustrated.

The names of outstanding surgeons of that time are reflected in eponyms used in the literature until today (Pott, Dupuytren, Maisonneuve fractures, Earle, Wagstaffe, Le Fort, Tillaux fragments).

2.2

Beginnings of radiology

Following Röntgen’s discovery in 1895, x-rays were rapidly introduced clinically, including also in ankle trauma surgery, with the French surgeons again dominating this field. One of the first was Victor Alexandre Henri Chaput (1857– 1919) who began to use radiological examination as early as around 1899. In 1907, he published an extensive study on ankle fractures “Les Fractures Malléolaires du Cou-de-pied et les Accidents du Travail” [13] (Fig 2-3), where he defined also the “ligne claire” (tibiofibular clear space) to be used to assess the condition of the tibiofibular syndesmosis (Fig 2-4). Of vital importance to the development of diagnosis and classification of ankle fractures was the textbook by Étienne Destot (1864–1918) “Traumatismes du Pied et Rayons X” published in 1911 [14]. Destot began to use radiological examination immediately after Röntgen’s discovery and summarized his extensive experience in a book, the first of its type ever published.

24

“

Of vital importance to the development of diagnosis and classification of ankle fractures was the textbook by Étienne Destot (1864–1918), ‘Traumatisme du Pied et Rayons X’, published in 1911.

”

The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

Radiology soon became the subject of a number of renowned textbooks, such as the Helferich’s atlas of fractures [15], Cotton’s [16], and Tanton’s [10] textbooks, and the early books on internal fixation published by Lane [17, 18] and Lambotte [19, 20]. Due to inadequate quality, some x-rays were initially presented often in the form of black-and-white drawings, or tracings, although Meissner in 1908 [21], Sussman König in 1912 [22], Hilgenreiner in 1913 [23] already published a number of interesting radiographs in their studies.

An outstanding radiological study based on assessment of 300 cases was published in 1922 by Ashhurst and Bromer [1]. This study supplemented by a number of drawings and radiographs was highly valued not only for its contribution to the English literature but also to the history of ankle fractures as a whole, and remained unequalled for a long time due to its comprehensive coverage. Another milestone was Bonnin’s textbook, published as late as 1950 [8].

a

b

Fig 2-3 Drawings from Chaput’s study [13].

Fig 2-2a–b Drawings of ankle fractures published by Malgaigne. a Fracture of distal fibula. b Bimalleolar fracture [12].

Fig 2-4 Chaput’s “ligne claire” [13].

25

2 A short history of ankle fractures

3 Development of radiological classifications Although the first attempts at classifying ankle fractures date back to the preradiological era, these classification schemes were based exclusively on experiments.

Only after the introduction of radiological examination was it possible to open a clinically relevant debate about this issue.

3.1

Chaput classification

The first classification of ankle fractures reflecting radiographic findings was published by Chaput in 1907 [13]. He based it on experimental studies of his predecessors, particularly Tillaux, and distinguished between four basic groups of fractures: • Abduction fractures • Adduction fractures • Supramalleolar fractures caused by adduction or abduction • Comminuted fractures

“

The first classification of ankle fractures reflecting radiographic findings was published by Chaput in 1907.

”

The first two groups are fracture dislocations, while the third and fourth groups include pilon fractures. Ample drawings used in the text show that Chaput had a good knowledge of all types of fibular fractures in terms of the level of fracture line. He described in great detail the fractures of the medial malleolus and fractures of the posterior rim of the distal tibia, distinguishing between different sizes of the avulsed fragment. He repeatedly mentioned Tillaux experimental studies and the fragment of anterior tubercle of the distal tibia described by him (Tillaux’s fragment externe) known today as the Tillaux-Chaput tubercle or fragment.

3.2

Destot classification

In 1911, Destot [14] introduced a concept which remains relevant today, consisting in division of ankle fractures into those compromising the stability of fracture dislocations, ie, fractures which involve only the mortise and disturb the equilibrium of the foot, versus those involving the “pilon tibial” or the tibial “pestle”, ie, the support of the body. Both groups were subdivided into individual patterns (Fig 2-5).

3.3

Tanton classification

Another classification of ankle fractures was published in 1916 by Tanton [10] who based it on the Destot’s concept, ie, distinguishing between malleolar and pilon fractures.

Malleolar fractures were subdivided into the isolated (medial or lateral malleolus) and the associated ones. The latter group included four fracture patterns, according to the level of the fibular fracture in relation to the syndesmosis (Fig 2-6): • Fractures bi-malléolaires basses (Weber A type) • Fractures de Dupuytren basses (Weber B type) • Fractures de Dupuytren types (low Weber C type) • Fractures de Maisonneuve (high Weber C type) Pilon fractures were divided into total and partial ones. In the latter group, he distinguished between isolated fractures and fractures combined with malleolar fractures. Therefore, pilon fractures included also fractures of both malleoli with

26

The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

Fig 2-5 Destot classification of malleolar fractures [14].

a

b

c

Fig 2-6a–c Tanton classification of fibular fractures. a Fractures bi-malléolaires basses. b Fractures de Dupuytren basses. c Fractures de Dupuytren types [10].

27

2 A short history of ankle fractures

a fracture of the posterior rim of the distal tibia (fracture of posterior malleolus).

Medial malleolar fractures were in Tanton classification divided into vertical and horizontal ones, and horizontal fractures into the following types (Fig 2-7): • Fractures de la pointe (fractures of the apex) • Fractures de la partie moyenne (fractures of the middle part) • Fractures de la base (fractures of the base, transverse, or vertical) 3.4

Lane contribution

In 1921 Lane [24] published an interesting article on ankle fractures in which he distinguished between abduction and adduction fractures. According to Lane, with the foot in adduction there first occurs a vertical medial malleolar fracture and then a transverse lateral malleolar fracture (Fig 2-8). Lane distinguished between three phases of an abduction fracture. He proposed that with abduction and external rotation of the foot, it is the fibula that is fractured first, followed by a medial malleolar fracture, or rupture of the deltoid ligament, and finally avulsion of a posterior tibial fragment of variable size. Although Lane was wrong regarding the sequence of lesions in adduction and abduction fractures, he was the first in the radiological era to present a categorization of ankle fractures based on the mechanism of injury.

a

a

28

b

c

b

“

According to Lane, with the foot in adduction there first occurs a vertical medial malleolar fracture and then a transverse lateral malleolar fracture.

”

Fig 2-7a–c Tanton classification of fractures of medial malleolus. a Fractures de la pointe. b Fractures de la partie moyenne. c Fractures de la base [10].

Fig 2-8a–b Lane grading of adduction fracture [24].

The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

nne.

Jan Bartonícek ˇ

3.5

Ashhurst-Bromer classification

Chaput, Destot, and Tanton died almost at the same time, at the end of World War I. Their premature deaths were probably caused also by personal suffering and tragedies they experienced during the war and in the case of Destot also by the radiation syndrome.

Fortunately, they had a worthy successor on the other side of the Atlantic, namely the American surgeon Astley Paston Cooper Ashhurst (1876–1932). His father, a prominent American surgeon John Ashhurst (1839–1900), named him after the famous English surgeon sir Astley Paston Cooper (1768–1841). During World War I, APC Ashhurst served in France where he cooperated with the French physicians and thus got acquainted also with publications by Chaput, Destot, Tanton, and others.

“

During World War I, APC Ashhurst served in France where he cooperated with the French physicians and thus got acquainted also with publications by Chaput, Destot, Tanton, and others.

”

In 1922, Ashhurst together with Bromer published a remarkable radiological study developed on the basis of a thorough review of the literature and of 300 ankle fractures [1]. Fractures were divided according to the mechanism of injury into: • Fractures by external rotation • Fractures by abduction • Fractures by adduction • Fractures by compression in long axis of leg • Fractures by direct violence (supramalleolar types) From the anatomical-pathological viewpoint, Ashhurst and Bromer distinguished five fracture patterns, namely a fracture of: • Fibula below the inferior tibiofibular joint • Fibula obliquely through the inferior tibiofibular joint • Fibula above the inferior tibiofibular joint • Tibia, involving the ankle joint • Supramalleolar fractures, not involving the ankle joint directly 3.6 Henderson classification In 1932, the American orthopedic surgeon Melvin Starkey Henderson (1883–1954) published an ankle fracture classification based on Tanton’s concept [25]. Using the term trimalleolar fractures that he introduced before, he divided the fractures into three groups: • Isolated malleolar fractures (including posterior malleolus) • Bimalleolar fractures (without and with displacement) • Trimalleolar fractures (medial, lateral, posterior)

In this way, Henderson resolved the drawback of the Tanton classification that included malleolar fractures combined with a posterior malleolar fracture into the group of pilon fractures. One year later in 1934 Henderson [26] slightly modified his classification scheme.

29

2 A short history of ankle fractures

3.7

Danis classification

In 1949, Robert Danis (1880–1862) published an extraordinary book on internal fixation “Théorie et Pratique de l’Ostéosynthèse” [27], part of which dealt with the surgical treatment of ankle fractures. Danis divided ankle fractures according to the level of the fibular fracture in relation to the syndesmosis into four groups (Fig 2-9): • A transverse fibular fracture below the insertion of both tibiofibular ligaments, caused most probably by adduction (fracture sous-ligamentaire).

• An oblique interligamentous fracture caused by torsion, where the anterior tibiofibular ligament is intact and the posterior tibiofibular ligament is torn or avulsed together with a tibial bone fragment (fracture inter-ligamentaire).

• An oblique fracture above the insertion of the tibiofibular ligaments onto the fibula caused by torsion where the anterior tibiofibular ligament is torn and the posterior tibiofibular ligament is also torn or avulsed together with a tibial bone fragment (fracture sus-ligamentaire basse).

• A transverse fracture of the fibula caused by abduction of the foot, located several centimeters above the insertion of tibiofibular ligaments on the fibula. Both ligaments are injured, including the interosseous membrane that is ruptured up to the level of the fracture of the fibula (fracture sus-ligamentaire haute).

Medial malleolar fractures were divided into transverse and vertical ones, a concept that may also be found in Malgaigne’s textbook. The above-mentioned overview shows that the Danis classification scheme of ankle fractures according to the course of the fracture line on the fibula was not original. The first to introduce such a scheme was Tanton [10], followed by Ashhurst and Bromer [1]. Danis’ contribution consists in associating the level of the fibular fracture with a certain type of lesion of tibiofibular ligaments, even if incorrect from the viewpoint of current knowledge.

a

b

c

“

Danis’ contribution consists in associating the level of the fibular fracture with a certain type of lesion of tibiofibular ligaments, even if incorrect from the viewpoint of current knowledge.

”

d

Fig 2-9a–d Danis classification of fibular fractures [27].

30

The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

4 Posterior fragment of distal tibia Fracture of the posterior rim of the distal tibia in ankle fracture dislocations is a subject of continuing interest. In the German-language literature, this fragment is commonly referred to as “Volkmann’sches Dreieck” [28], while English-language authors prefer the term “posterior malleolus” or “posterior rim (edge) of distal tibia” [1, 29, 30].

4.1

The first description

Sir Astley Paston Cooper (1768–1841) is sometimes presented as the first author to describe avulsion of the posterior rim of the tibia, namely in 1819 in Surgical Essays [31] and later in 1822 in A Treatise on Dislocations [32]. However, the description and drawings show that it was a fracture of the tibial pilon rather than a fracture dislocation of the ankle (Fig 2-10). Thus, the first to describe this injury was probably Henry Earle (1879–1838), grandson of Percival Pott, in 1828, namely on the basis of autopsy findings [33].

4.2

“

Sir Astley Paston Cooper (1768–1841) is sometimes presented as the first author to describe avulsion of the posterior rim of tibia.

”

Volkmann’s triangle

In the German-language literature, the separated posterior rim of tibia is referred to as “Volkmann’sches Dreieck” (Volkmann’s triangle) [28]. However, this term is not correct, as repeatedly pointed out by some authors [2–6]. The drawings and description suggest that Richard von Volkmann (1810–1885) described avulsion

Fig 2-10 Cooper’s drawings of ankle fractures [32].

31

2 A short history of ankle fractures

of the lateral part of the distal tibia in the sagittal plane, apparently a compression fracture, ie, a tibial pilon fracture, as shown also by his original drawings (Fig 2-11). In no case did he describe avulsion of the posterior fragment of the distal tibia, and avulsion of the anterior tibial fragment was mentioned only marginally [34]. Thus, Volkmann’s is the first known description of a successful operative treatment of an open fracture of the tibial pilon (resection of the distal tibia), rather than avulsion of a posterior tibial fragment.

The term “Volkmann’sches Dreieck” appeared in the German-language literature in the 1920s. One of the first surgeons to use it was probably Karl Ludloff (1864– 1945) [35, 36] in 1926 who was followed in 1931 by Fritz König (1866–1952) [37] and Fritz Felsenreich [38, 39]. After World War II, the term “Volkmann’sches Dreieck” was adopted by a number of German surgeons [28]. In the first AO textbook from 1963, Willenegger and Weber used the term Earle-Volkmann type [40]; however, in the last issue of the AO manual from 1991 [41] it is referred only as the Volkmann triangle. Weber in his textbook from 1966 [9] used Earle’s name for the avulsed posterior tibial fragment, and he associated avulsion of the anterior tibial fragment with the Volkmann name.

“

Volkmann’s is the first known description of a successful operative treatment of an open fracture of the tibial pilon.

”

4.2.1 Posterior malleolus

The term “malléole postérieure” (posterior malleolus) was introduced by Destot [14] in 1911. In his view, fractures of the posterior malleolus may occur either in a combined or an isolated form. In 1912, Birscher [42] suggested the term “malleolus lateralis posterior” which, however, has not been accepted.

4.2.2 Cotton fracture

In 1915, Frederic Jay Cotton (1869–1938) described a “new type” of ankle fracture that was later associated with his name [43]. It was a fracture of both malleoli in conjunction with a fracture of the posterior rim of the distal tibia (Fig 2-12). Cotton, however, was wrong. The same fracture was described by Robert Adams (1795–1871) as early as in 1836 [44] in a 53-year-old woman who sustained “…the partial dislocation forwards of the tibia, combined with a simple fracture of the fibula.” The woman subsequently died and the autopsy revealed that “…the internal malleolus itself had been broken, and small portion of the back part of the edge of the articular cavity of the tibia was avulsed.”

Description of this case is highly valuable as it was illustrated by two drawings of the affected limb (lateral and medial) and two drawings of the joint skeleton.

32

“

The term “malléole postérieure” (posterior malleolus) was introduced by Destot in 1911.

”

The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

a

b

Fig 2-11a–b Drawing of Volkmann’s cases. a Scheme of fracture lines. b Line R marks the level of resection [34].

Fig 2-12 Cotton’s drawings of “Cotton fracture” [43].

33

2 A short history of ankle fractures

4.2.3 Classification

The efforts to classify fractures of the posterior rim of the distal tibia appeared soon after this fracture was first described on a radiograph by Chaput [13] in 1907. In 1913 Grondahl [45] divided this fracture pattern into three groups, namely “proper fractures of posterior lip, fractures of posterolateral corner of distal tibia, and fractures consisting of cortical avulsion from the dorsal surface of the tibia.”

Souligoux [46] in his classification that was published in 1913 also distinguished between three types of injury to the posterior rim. In the first pattern only “the posterior tubercle” was avulsed, and the rest of the posterior rim remained intact.

In the second pattern the entire posterior rim (lip or edge) was avulsed as “a thin bone lamella.” The third pattern included also fractures of the entire rim, namely in the form of “a conical fragment on wider base carrying a piece of articular surface of varying size.” In 1922 Ashhurst and Bromer [1] introduced a classification of the avulsed posterior fragments according to their size into “small, medium and large fragments.”

“

In 1922 Ashhurst and Bromer [1] introduced a classification of the avulsed posterior fragments according to their size into small, medium and large fragments.

”

In 1940 Nelson and Jensen [47] divided fractures of the posterior rim of the distal tibia into “classic fractures” involving more than one third, and “minimal fractures” involving less than one third of the articular surface (Fig 2-13). In the classic type the authors’ recommended internal fixation by a screw via a posteromedial approach. The recommendation to reduce and fix operatively any posterior rim fragment bearing at least one third of the articular surface was accepted by a number of other authors and is, in fact, generally respected even now.

4.2.4 Operative treatment

The first authors who focused in detail on ankle fractures with a separated posterior fragment at the beginning of 20th century, eg, Meissner [21], Birscher [42], Sussman König [22], Hilgenreiner [23] and others were aware of instability of this type of fracture. They recommended foot traction, or even tenotomy of the Achilles tendon. Poor maintenance of ankle joint reduction in this way rather than the joint incongruence led to the first attempts at operative treatment of these fractures.

Fig 2-13 Nelson and Jensen classification of fracture of posterior fragment [47].

34

The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

5

Beginnings of operative treatment

A powerful impulse for the development of classification and operative treatment of ankle fractures was given only after it was possible to establish an exact diagnosis, ie, identify individual fragments and the degree of their displacement. It is no wonder that the first radiologically documented cases of internal fixation of ankle fractures appeared in the same period as the above-mentioned radiological studies [4].

Operative treatment of ankle fractures was launched simultaneously by William Arbuthnot Lane (1856–1943) and Albin Lambotte (1866–1955) as early as the first decade of the 20th century [17–20]. Within the period 1905–1914, they described technical principles that are still observed today. Lane preferred plate osteosynthesis, which he applied primarily in the fibular fractures, including suprasyndesmotic fractures and vertical fractures of the medial malleolus (Fig 2-14). Lane fixed transverse fractures of the medial malleolus with a screw.

Lambotte, on the other hand, never used a plate and preferred screws or nails in the internal fixation of both malleoli (Fig 2-15).

a

b

“

Operative treatment of ankle fractures was launched simultaneously by William Arbuthnot Lane (1856–1943) and Albin Lambotte (1866– 1955) as early as the first decade of 20th century.

”

c

Fig 2-14a–c Lane technique of fixation of fibular fractures by plate. a Fibular fracture. b Medial malleolus fracture. c “Antiglide” technique [17, 18].

Fig 2-15 Lambotte screw technique [20].

35

2 A short history of ankle fractures

These two authors presented the technique of wire cerclage and also of tibiofibular (“syndesmotic”) screws used to fix both a fractured fibula (fibula pro tibia) and tibiofibular diastasis (Fig 2-16). It is difficult to state which of the two authors was the first in this respect. Lambotte’s first case dates back to 1903 but was published as late as 1907 (Fig 2-17) [19]. Lane’s cases may be found without specification of the date in his 1905 book [17].

In 1912 Emil H Beckman (1872–1916) from the Mayo Clinic in Rochester was probably the first who published in United States [48] a radiograph of a fracture of the medial malleolus fixed with a plate.

Another prominent advocate of internal fixation of fractures was Ernst William Hey Groves (1872–1944) but he mentioned internal fixation of ankle fractures only briefly [49, 50]. In 1918, he described a technique of so-called bolted plates, ie, internal fixation of both malleoli by plates fixed together with a bolt, which he was most probably the first to use [49].

Internal fixation of the ankle was covered in great detail by Jacques Leveuf (1885–1948) in 1925 [51]. He used various techniques for internal fixation of the fibula, ie, wire cerclage, a tibiofibular screw, or a plate. He was the first to describe a combination of a plate and a tibiofibular screw (Fig 2-18).

In 1930, Karl Ludloff (1864–1945) [52] performed the first tibiofibular syndesmosplasty, using a tendon graft (Fig 2-19). In 1940, Philip Lewin [53] recommended stabilizing the tibiofibular mortise with a wire loop (Fig 2-20).

“

In 1930, Karl Ludloff (1864–1945) performed the first tibiofibular syndesmosplasty, using a tendon graft.

”

The contribution of Robert Danis, considered as one of the fathers of modern internal fixation, to the operative treatment of ankle fractures is somewhat controversial. In both his books published in 1932 [54] and 1949 [27], he completely ignored the medial malleolus. He fixed lateral malleolar fractures with wire cerclage, a short “intramedullary” nail, or a combination of both or with a cancellous screw inserted through the distal fibula into the tibia (Fig 2-21).

Rather questionable was also the quality of reduction of fragments of the fibular malleolus. He used a bolt for stabilization of the tibiofibular mortise.

Operative treatment of posterior malleolar fractures lagged behind the operative treatment of fractures of the lateral and medial malleoli. The first attempts were reported in the early 1920s. Internal fixation of a fracture of the posterior rim of the distal tibia was first published in 1922 most probably by Lounsbury and Metz [29]. They used the posteromedial approach to perform open reduction of the

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The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

Fig 2-16 Lambotte technique of stabilization of tibiofibular syndesmosis [20].

Fig 2-17 Lambotte case of ankle fracture treated by “syndesmotic” screw [19].

Fig 2-18 Leveuf technique of combination of fibular plate and “syndesmotic” screw [51].

Fig 2-19 Ludloff technique of syndesmoplasty by tendon graft [52].

Fig 2-20 Lewin technique of stabilization of tibiofibularis mortise by wire loop [53].

Fig 2-21 Danis technique of fixation of bimalleolar fracture by wire loop and transsyndesmotic cancellous screw. The fracture of the medial malleolus was neglected [27].

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2 A short history of ankle fractures

posterior fragment and fixed it with a bone peg inserted in the anteroposterior direction (Fig 2-22). In 1925, Leveuf [51] described reduction of the posterior malleolar fragment via a posterior Delbet transachillary approach, its fixation with a screw inserted in a posteroanterior direction, and a simultaneous internal fixation of the distal fibula, also with a screw (Fig 2-23). In 1926 [36] and 1927 [37] Ludloff published reports of open reduction and internal fixation of an irreducible fracture of the posterior malleolus via the posterolateral approach (Fig 2-24).

The use of operative treatment was significantly promoted by the above-mentioned study published by Nelson and Jensen [47] in 1940. In 1942, Rostock [55] recommended, after open reduction and internal fixation of the posterior fragment of the distal tibia, to check the accuracy of reduction by a radiograph taken before closure of the surgical wound. In 1947, Venable and Stuck [30] described anatomical reduction and fixation of the posterior fragment with screws via the posterolateral approach, in combination with internal fixation of the lateral malleolus using a plate. In 1949, Danis [27] recommended internal fixation of the posterior malleolar fragment with a screw also via the posterolateral approach.

“

Internal fixation of a fracture of the posterior rim of the distal tibia was first published in 1922 most probably by Lounsbury and Metz.

”

All the above-mentioned techniques were adopted by AO/ASIF and included into its armamentarium at the beginning of the 1960s [40, 41]. Its protagonists modified individual implants and added wire tension loop to this repertoire but no substantial change was made in the operative technique until the end of the 20th century.

6 Conclusion The above-mentioned overview shows that the foundations of radiological examination, classification, and operative treatment of ankle fractures were laid in the first quarter of the 20th century. The most important role in this process was played by the French surgical school and authors publishing in French.

Danis’ contribution to classification as well as to operative treatment of ankle fractures is largely overestimated, while those of Tanton, Lane, and Lambotte remain rather underappreciated.

Acknowledgments This study could not have been possible without the extraordinary help in collecting original sources by Ludmila Frajerová from the Klementinum (Czech National Library) and Mirka Plecitá from the 3rd Faculty of Medicine, Charles University, Prague. I also extend appreciation to Ludmila Bébarová and Professor Chris Colton, MD, FRCS, for editing the English version of this chapter.

This chapter was supported under the grant AZV Č R 16-28458A: Trimalleolar fractures of the ankle-CT diagnostics of fractures of posterior malleolus, their CT classification, operative treatment.

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The Foot: Arts, Myths, and Secrets Stefan Rammelt, Hans Zwipp

Jan Bartonícek ˇ

Fig 2-22 The open reduction and fixation of fracture of the posterior fragment performed by Lounsbury and Metz [29].

Fig 2-23 Internal fixation of fracture of the posterior malleolus and distal fibula via transachillary approach after Leveuf [51].

Fig 2-24 Ludloff technique of fixation of fracture of posterior malleolus [52].

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2 A short history of ankle fractures

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