The heel of achilles: calcaneal avulsion fracture from a gunshot wound

Greek mythology relates that the legendary warrior Achilles was made invincible by his mother Thetis, who dipped him in the River Styx while holding him by his heel. Because his heel was never immersed, it remained his one area of vulnerability. After the fall of Troy, Achilles met his demise when he was shot in the heel by Paris, whose arrow was guided by the Greek god Apollo. This is the derivation of the term "Achilles tendon." Avulsion fractures of the tuberosity of the calcaneus are rare injuries. Schonbauer reviewed a series of 870,000 accident cases treated at the Vienna Trauma Hospital and found only four such cases in addition to 151 cases of subcutaneous Achilles tendon rupture. In Bohler's series of 182 calcaneal fractures, avulsion of the calcaneal tuberosity accounted for less than 1% of these injuries. Rowe reported four Achilles avulsion fractures in his series of 154 calcaneal fractures. Three basic mechanisms of injury have been described: (1) dorsiflexion violence against the maximally plantarflexed foot, typically occurring in a fall from a height; (2) powerful contraction of the triceps surae muscle with simultaneous extension of the knee such as when a person is about to sprint in a race; (3) a direct blunt blow to the hindfoot. We are describing a case of avulsion of the calcaneal tuberosity due to direct penetrating trauma from a gunshot wound, a mechanism not previously reported.

Supramalleolar osteotomy for the treatment of symptomatic tibial malunion

Supramalleolar osteotomy was performed on eight patients who were symptomatic from a malunion of the distal two-thirds of the tibia. The patient's subjective reports of pain, limp, appearance, instability, and limitation of activity were evaluated pre- and postoperatively. Objective measurements of range of motion, angular deformity, and radiographic signs of ankle arthritis were also evaluated. All of the patients had varus malunion with a mean angulation of 15 degrees. Three of these patients also had sagittal malalignment. Supramalleolar dome or wedge osteotomies were performed to correct the coronal and sagittal plane deformities. Either internal (three patients) or external (five patients) fixation devices were applied to maintain correction. All osteotomies healed. The final mean angulation was 0 degrees in the coronal plane and 8 degrees of recurvatum. Complications included pin tract infections, wound breakdown, failure to completely correct the deformities, and loss of reduction. Seven of the patients reported symptomatic improvement after the procedure. The one patient who had a loss of reduction became more symptomatic.

Chronic non-hematogenous osteomyelitis treated with adjuvant hyperbaric oxygen

Between 1979 and 1982, thirty-eight patients with chronic non-hematogenous osteomyelitis were treated by local débridements of the wound, prolonged parenteral administration of antibiotics, and an average of forty-eight once-a-day treatments with hyperbaric oxygen. Of these thirty-eight patients, thirty-four remained free of clinical signs of osteomyelitis for an average of thirty-four months (range, twenty-four to fifty-nine months) after this regimen of treatment. Only four of the thirty-eight patients had been free of clinical signs of osteomyelitis for as long as three months during the two years preceding this treatment. Three of the four failures of treatment were evident within one month after treatment. This method of treatment appears to prolong the infection-free interval of patients with chronic non-hematogenous osteomyelitis.

Comparison of skeletal traction forces in patients treated in conventional and oscillating hospital beds

This study compares the forces in two types of skeletal traction systems: a standard hospital bed with balanced suspension traction and an oscillating hospital bed using a flexion cable system. In line traction, forces were continuously measured, using a specially designed transducer. Changes in the magnitude of traction forces of up to two times the applied force were caused by patient movement, nursing procedures, and changes in bed configuration. The oscillating hospital bed was found additionally to impart a moderate (20-50%) rhythmic, sinusoidal variation in applied traction forces. The traction forces applied with the flexion cable system on the oscillating hospital bed were well tolerated and equivalent to those applied in conventional balanced suspension on a standard hospital bed. Although different in design, standard balanced suspension traction on a conventional hospital bed and traction using the flexion cable system on the oscillating hospital bed appear to be equally effective in stabilizing fracture sites.

Fractures of the lateral process of the talus

A retrospective review of nine patients with fractures of the lateral process of the talus indicates that a substantial portion of patients will have persistent symptoms if the fracture is not diagnosed and appropriately treated soon after the injury. When a patient is evaluated for the symptoms of a "sprained ankle," these fractures are often overlooked on the initial roentgenograms. If untreated, these fractures often fail to heal, and persistent pain over the lateral aspect of the ankle following an inversion injury should be investigated for the possibility of this diagnosis. Prompt treatment of acute fractures appears to lead to the best result. Nondisplaced fractures heal well in a short-leg cast, with six weeks of immobilization. Large displaced fracture fragments require surgical treatment: single large fragments should be reduced and internally fixed, and large comminuted fragments should be excised.

Distal patellar pole fractures. A proposed common mechanism of injury

A variety of names has been given to disorders of the inferior pole of the patella occurring in young athletic individuals and several different causes have been proposed for these disorders. Occasionally a direct blow will cause fracture of the inferior pole of the patella, but the only other mechanism which seems to be responsible is subluxation or dislocation. Ten cases of distal patellar pole fracture secondary to dislocation or subluxation of the patella are reported. From these cases and an extensive review of the literature it is concluded that patellar subluxation or dislocation is the usual common mechanism of distal patellar pole fractures in young, active individuals and that adequate treatment of this problem must address the patellar instability as well as the fracture.

Traumatic plastic deformation of the radius and ulna. A closed method of correction of deformity

More than 50 cases of plastic deformation of the forearm in children have been reported in the literature, but no method of reduction other than osteoclasis has been described. Fourteen patients with plastic deformation of one or both bones of the forearm were observed over a period of five years. Of these 14, nine were cared for acutely, and a closed reduction was performed by placing the apex of the plastically deformed bone over a fulcrum and applying significant pressure for several minutes. The average correction was 85% of the angulation present prior to reduction. The clinical findings in these patients treated by closed reduction were compared with those observed in untreated cases seen by the authors and those in the literature. Early reduction of the plastic deformation decreased the clinical deformity, allowed treatment of adjacent fractures, and led to earlier return of full pronation and supination of the forearm.

Principles and techniques of splinting musculocutaneous injuries

Splinting should be used as soon after a musculoskeletal injury as possible, and the splint should be maintained (in some form) until the injury is healed to the extent that protected limb function can be resumed without pain. This principle is the overriding guide to the appropriate pre-hospital management of these injuries. In the emergency department, the physician performs a careful physical examination, without removing the splint if possible, and takes the patient's history in order to arrive at an accurate diagnosis before the splinted patient is sent for x-ray evaluation.

Emergency department evaluation of the swollen joint

Pain, swelling, and limited range of motion of a joint are extremely common complaints in the emergency department. In assessing joint complaints it is helpful for the emergency physician to keep in mind the major categories of diagnostic possibilities; it is also useful to distinguish between chronic and acute problems and between monoarticular and polyarticular problems. The emergency physician does not need to make a precise diagnosis of every joint complaint, but it is essential that infectious arthritis not be missed.

Tendon lacerations in the foot

An extensive search of the English and foreign language literature yields clinical reports on only 87 patients with open injuries of various tendons about the foot and ankle. This retrospective review is presented to document case histories in 80 additional patients, to present the results of 46 patients, and to assess the treatment recommendations outlined in the literature.

Eikenella corrodens in human bite infections of the hand

Over a 51/2-year period 30 patients were found with Eikenella corrodens infections of the hand following closed fist injury. Twenty-four had mixed infections; six grew pure cultures of Eikenella. Twenty-one of the 30 patients had positive cultures from an injured metacarpophalangeal joint. A delay in presentation or an inaccurate initial diagnosis appeared to be the most significant factors leading to the complications of osteomyelitis (in five patients) and significant loss of joint function (in eight other patients). Clinicians must have a high index of suspicion when evaluating any hand injury and clenched fist injuries of the hand should be treated by early adequate surgical debridement followed by IV penicillin given until operative cultures confirm or deny contamination with Eikenella corrodens.

Supracondylar-intercondylar fractures of the femur treated with a supracondylar plate and lag screw

Twenty-six patients ranging from nineteen to ninety-two years old underwent rigid internal fixation of supracondylar-intercondylar fractures of the distal end of the femur, using a supracondylar plate and lag screw to achieve two-plane fixation. The congruity of the articular surface of the knee was anatomically restored, as were the mechanical and anatomical axes of the lower extremity. The time to clinical and roentgenographic union averaged four months. There were no non-unions or postoperative infections. The average postoperative range of motion of the knee was 120 degrees. The average length of follow-up was twenty-one months. This series demonstrates the advantages of stable internal fixation using a supracondylar plate and lag screw over other types of fixation.

Partial fibulectomy for ununited fractures of the tibia

Despite the improved rate of union reported with early weight-bearing in tibial shaft fractures, there continues to be a small number of patients with delayed union and non-union who present a dilemma to the surgeons. Partial fibular ostectomy (fibulectomy) is one means of promoting union in ununited fractures of the tibia. Fifty-one patients at our hospital underwent that treatment between December 1, 1971 and June 30, 1979, at twenty to fifty-nine weeks after the date of injury. Following the partial fibulectomy, 77 per cent of the tibial fractures healed. Failure of union after fibulectomy was associated with either failure of the patient to bear weight postoperatively, the presence of a true pseudarthrosis at the fracture site, or previous prolonged treatment of the initial fracture with external fixation. Partial fibulectomy proved to be a relatively effective and simple method for the treatment of ununited fractures of the tibial shaft.

Interstitial tears of the posterior cruciate ligament of the knee

We reviewed the records of 10 patients who suffered complete interstitial tears of their posterior cruciate ligaments. Five patients had isolated posterior cruciate tears, confirmed at arthrotomy. The most reliable clinical findings for posterior cruciate disruption were a posterior drawer sign and a posterior sag. All patients underwent surgical repair, with reinforcement using the tendon of the medial head of the gastrocnemius. Seven of the 10 patients were seen at followup examinations an average of 22 months after surgery. Each had a posterior drawer sign, but none had a posterior sag or recurvatum. The results do not approach the uniform good results of posterior cruciate avulsion injuries, but do show improvement over the results of nontreatment.

Traumatic closed transection of the biceps brachii in the military parachutist

Static line injury to the military paratrooper's arm occasionally produces an unusual muscle injury: closed transection of the belly of the biceps brachii. A review of twenty-eight untreated paratroopers so injured demonstrated significant residual weakness and deformity. Attempts at late repair resulted in only minimum improvement. The results of twenty fresh injuries treated by either surgical repair or aspiration followed by closed reduction and splinting are presented.