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THE CLASSIC: Some Few General Remarks on Fractures and Dislocations

2007; Lippincott Williams & Wilkins; Volume: 458; Linguagem: Inglês

10.1097/blo.0b013e31803dd063

1528-1132

Percival Pott,

Musculoskeletal Disorders and Rehabilitation

Percival Pott of London (1714-1788) served on the staff of St. Bartholomew's Hospital from 1744 until 1787 shortly before his death. He wrote a number of important monographs during this period, among which was “Some Few General Remarks on Fractures and Dislocation.” In this book appeared the first definitive description of fracture about the ankle. It is memorable in that it describes a variety of fracture forms previously merely referred to as a single injury. Equally important, though still not always adequately appreciated, it discussed the importance of coincidental injuries to the soft tissues about the ankle and the tarsus, the proper care of which so greatly influences recovery. This group of fractures and soft tissue injuries still preserves the eponym of Pott's fracture, actually a generic term rather than the definition of a single fracture. E.M.B. I have already said, that in most cases of broken thigh or leg, the method just described will be attended with great success: but there is one particular case in which its utility is still more conspicuous; a case, which according to the general manner of treating it, gives infinite pain and trouble both to the patient and surgeon, and very frequently ends in the lameness and disappointment of the former, and the disgrace and concern of the latter: I mean the fracture of the fibula attended with a dislocation of the tibia. Whoever will take a view of the leg of a skeleton will see that although the fibula be a very small and slender bone, and very inconsiderable in strength, when compared with the tibia, yet the support of the lower joint of that limb, (the ankle) depends so much on this slender bone, that without it the body would not be upheld, nor locomotion performed, without hazard of dislocation every moment. The lower extremity of this bone, which descends considerably below that end of the tibia, is by strong and inelastic ligaments firmly connected with the last-named bone, and with the astragalus, or that bone of the tarsus which is principally concerned in forming the joint of the ankle. This lower extremity of the fibula has, in its posterior part, a superficial sulcus for the lodgment and passage of the tendons of the peronei muscles, which are here tied down by strong ligamentous capsulae, and have their action so determined from this point or angle, that the smallest degree of variation from it, in consequence of external force, must necessarily have considerable effect on the motions they are designed to execute, and consequently distort the foot. Let it also be considered, that upon the due and natural state of the joint of the ankle, that is, upon the exact and proper disposition of the tibia and fibula, both with regard to each other and to the astragalus, depend the just disposition and proper action of several other muscles of the foot and toes; such as the gastrocnemii, the tibialis anticus, and posticus, the flexor pollicis longus, and the flexor digitorum pedis longus, as must appear demonstra-bly to any man who will first dissect and then attentively consider these parts. If the tibia and fibula be both broken, they are both generally displaced in such manner, that the inferior extremity, or that connected with the foot is drawn under that part of the fractured bone, which is connected with the knee; making by this means a deformed, unequal tume-faction in the fractured part, and rendering the broken limb shorter than it ought to be, or than its fellow. And this is generally the case, let the fracture be in what part of the leg it may. If the tibia only be broken, and no act of violence, indiscretion, or inadvertence be committed, either on the part of the patient or of those who conduct him, the limb most commonly preserves its figure and length; the same thing generally happens if the fibula only be broken, in all that part of it, which is superior to letter A in the annexed figure, or in any part of it between its upper extremity, and within two or three inches of its lower one. I have already said, and it will obviously appear to every one who examines it, that the support of the body and the due and proper use and execution of the office of the joint of the ankle depend almost entirely on the perpendicular bearing of the tibia upon the astragalus, and on its firm connection with the fibula. If either of these be perverted or prevented, so that the former bone is forced from its just and perpendicular position on the astragalus, or if it be separated by violence from its connection with the latter, the joint of the ankle will suffer a partial dislocation internally; which partial dislocation cannot happen without not only a considerable extension, or perhaps laceration of the bursal ligament of the joint, which is lax and weak, but a laceration of those strong tendinous ligaments, which connect the lower end of the tibia with the astragalus and os calcis, and which constitute in great measure the ligamentous strength of the joint of the ankle. This is the case, when by leaping or jumping the fibula breaks in the weak part already mentioned, that is within two or three inches of its lower extremity. When this happens, the inferior fractured end of the fibula falls inward toward the tibia, that extremity of the bone which forms the outer ankle is turned somewhat outward and upward, and the tibia having lost its proper support, and not being of itself capable of steadily preserving its true perpendicular bearing, is forced off from the astragulus inwards, by which means the weak bursal, or common ligament of the joint is violently stretched, if not torn, and the strong ones, which fasten the tibia to the astragalus and os calcis, are always lacerated, thus producing at the same time a perfect fracture and a partial dislocation, to which is sometimes added a wound in the integuments, made by the bone at the inner ankle. By this means, and indeed as a necessary consequence, all the tendons which pass behind or under, or are attached to the extremities of the tibia and fibula, or os calcis, have their natural direction and disposition so altered, that instead of performing their appointed actions, they all contribute to the distortion of the foot, and that by turning it outward and upward. When this accident is accompanied, as it sometimes is, with a wound of the integuments of the inner ankle, and that made by the protrusion of the bone, it not infrequently ends in a fatal gangrene, unless prevented by timely amputation, though I have several times seen it do very well without. But in its most simple state, unaccompanied with any wound, it is extremely troublesome to put to rights, still more so to keep it in order, and unless managed with address and skill, is very frequently productive both of lameness and deformity ever after. After what has been said, a farther explanation why this is so is unnecessary. Whoever will take even a cursory view of the disposition of the parts, will see that it must be so. By the fracture of the fibula, the dilatation of the bursal ligament of the joint, and the rupture of those which should tie the end of the tibia firmly to the astragalus and os calcis, the perpendicular bearing of the tibia on the astragalus is lost, and the foot becomes distorted; by this distortion the direction and action of all the muscles already recited are so altered, that it becomes (in the usual way of treating this case) a difficult matter to reduce the joint, and, the support of the fibula being gone, a more difficult one to keep it in its place after reduction. If it be attempted with compress and strict bandage, the consequence often is a very troublesome as well as painful ulceration of the inner ankle, which very ulceration becomes itself a reason why such kind of pressure and bandage can be no longer continued; and if the bone be not kept in its place, the lameness and deformity are such as to be very fatiguing to the patient, and to oblige him to wear a shoe with an iron, or a laced buskin, or something of that sort for a great while, or perhaps for life. All this trouble, pain, difficulty, and inconvenience are occasioned by putting and keeping the limb in such position as necessarily puts the muscles into action, or into a state of resistance, which in this case is the same. This occasions the difficulty in reduction, and the difficulty in keeping it reduced; this distorts the foot, and by pulling it outward and upward makes that deformity, which always accompanies such accident; but if the position of the limb be changed, if by laying it on its outside with the knee moderately bent, the muscles forming the calf of the leg, and those which pass behind the fibula and under the os calcis, are all put into a state of relaxation and non-resistance, all this difficulty and trouble do in general vanish immediately; the foot may easily be placed right, the joint reduced, and by maintaining the same disposition of the limb, every thing will in general succeed very happily, as I have many times experienced.