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A Device

for Stress

inversion of the
MediCal Corps, Fort United
Carson,

or Eversion Ankle
Stales Army Reserve
Colorado

Roentgenograms
BY CAPTAIN Front ELIAS the D. SEDLIN. States United Army

Hospital,

The eversion procedure injuries
method

use stress
in

of roentgenograms to the foot,
an

of the has been the
accurate

ankle, discussed
diagnosis

made
in

while
acute or

applying
113

inversion an important
ligamentous

or

frequently has
The

as

establishing

chronic

of
that

the

ankle.
has

Customarily,
disadvantages.

stress

been
large

applied
number of

manually
ligamentous

-

a

obvious

injuries lated

the

of the ankle development

sustained of a

by Army recruits at Fort Carson, Colorado, device for obtaining these roentgenograms of the stress. and use of It minimizes an the apparatus surgeon’s foot

stimuwhich which has exposure

eliminates the need for manual application This article describes the fabrication proved entirely satisfactory and practical. to radiation, conserves of the roentgenograms, technique.
with ease.

his time, and eliminates motion of the a frequent cause of poor roentgenograms easy
the

during exposure with the manual

It is inexpensive,
In my experience,

to apply,
apparatus

and

compact has proved

enough to be transported of definite value when

stress

roentgenograms

were

indicated.
THE DEVICE

The

device

consists

of a foot

piece,

an

anchoring

thigh

strap,

and

two

con-

necting ropes which shop (Figs. 1 through aluminum for turret clamps; for the retaining clamps; clothesline the
two

can be assembled 3). The materials ; enough steel

quickly needed

and inexpensively in include two 16-gauge

any brace sheets of for the inches,

foot plate cold-rolled

24-ST aluminum rods, three-eighths

or the equivalent of an inch by six

connecting rods; welding rod, one-eighth of an inch in diameter, for the rings ; steel wire, three-sixteenths of an inch in diameter, for the rope one-inch webbing for the thigh strap; and approximately five feet of for the connecting rope. Fabrication of the apparatus includes rods, with shaping of the turret rope clamps. clamps and connecting The foot piece is padded the wide foot. and and bending one-half inch and two inches in inversion or neutral
follows : The is

of the foot plates, drilling of the retaining rings and thick ropes length, felt are over the attached

surfaces that are in contact with to a piece of webbing, one-inch

A buckle eighteen

to make the anchoring strap (Fig. 2). The device fits any adult foot and it can be adjusted to maintain or eversion of the foot with the ankle in dorsiflexion, plantar flexion,
chosen on

position,

the to

basis

of clinical

findings.

It of parts

is easily

applied An

as

two
so

parts
that they

of the firmly

foot around The t.he
or

piece the

are
the

slid
heel

together
and fore

along
part two

the
the

connecting
foot. of the

rods
elastic

and

adjusted just clamps, stress is foot
to be of the

conform

bandage

wrapped above either utilized.
*

foot

and

the rods

foot

piece, the

starting turret

the

ankle. When

connecting depending rods
contained

are on

then whether
are those

slid

through inversion the

medially
The
opinions

or laterally, connecting
assertions

or eversion plates

are
of the

in proper
Department

position,

of the

herein

construed
Army, I 184

as official or the Office

the views of the Surgeon General.
or reflecting

of the author and are not of Defense, The Department

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

2 loot and VOL. it Ii anchor strap attached: (1 = metaimiing ring. 7. b = clamping screw.A DEVICE FOR STRESS ixvsmox OR EVERSIOX 1185 Lateral view of the taming ring: an(l e = foot piece: = heel flange. e = connecting rod: (I = rope clamp. OTOBEIt 1960 . FIG. 42-A. ni ahove. b = rope clamp. C = liiece viewed fr rod. connecting No.

4 screw. All tests reasonably to assure performed testing the same amount three individuals. as of the AND JOINT about one the device the foot roentpiece rotation bars BONE the JOURNAL cross OF SURGERY . To ropes are pulled through the tapered taut . the device the foot has when was used when of talar instances a flat the used the tilt obtained revealed anteroposterior the to and angle the in several difference surface held patient for the at the heel. is accomplished is a simiple procedure it has l)een achieved. D. position for For this reason. Vig. were used comparable conditions throughout. the are sufficiently of the calcaneofibular ligament. to the applied that by acutely point was ankle as the amount of stress sistance to further inversion mined quantitatively. just al)ove the knee. in an oblique Comparison mortise determined. Both roentgenograms an from no anteroposterior were and obtained. was determined in the normal and to The in the the anesthetized. dependThe adjustment the foot in equinus or iii neutral position ing omi whether inversiomi or eversiomi stress is to I)e applied. 3 FIG. perpendicular is naturally in the is lying most appropriate supine. maintain the desired position of the slots of the rope clamps until they and mio moamid overlying ankle as the injured tion felt of the hold The the foot foot can Properly applied. 3: Foot 4: Lower piece as extremity viewed with device from below: applied a = for turret stress clamp inversion and S = clamping roentgenogram. external by or internal fixing THE requires If desired. invert amount taken were ankle of stress where renot deter- in that nor were precautions all ankles. of stress was used and it is thought needed felt. take place because the curves of the flanges was rigidly. piece are squeezed against the foot. length of the anterior cord allows stress to be applied with tion for the testing of the anterior talofibular ligament of the posifor the testimig ankle.1186 E. amoumit amount needed of stress to be applied to just cause discomfort. with the two ropes anchoring on either strap is applied around the thigh the medial or lateral side. Fig. the device remains imi position. The amid the screws of the turret clamps are tight- ened against the cominecting rods. SEDLIN FIG. long axis or mortise view were of the measurements roentgenograms Since of the foot. part. an anteroposterior the anteroposterior projection projection that The minute can be genogram application of the device once proficiency in applying used to apply This stress in either is made.

ankle. 7. Exploration demonstrated a tear of the anterior talofibular ligament and the lateral capsule and an incomplete tear of the calcaneofibular ligament. Anesthesia 1960 not used. 6-B: Stress 7: Stress inversion inversion the a contralateral sergeant. twenty-two years old. FIG. 7 Fig. Femoral-nerve and sciatic-nerve block was used. was with not :i used. ankle. Fig. 42-A. Femoral-nerve and sciatic-nerve block was used.A DEVICE FOR STRESS iNVERSION OR EVERSJON 1187 Fio. 5 FIG. The tilt of the contralateral ankle was nil. OCTOBER . NO. 6-B roentge’nogram roentgenogram was of FIG. 5: Stress inversion roentgenogram of a recruit. Fig. 6-A Fig. 6-A: Stress inversion roentgenogram of a recruit. with an acute injury. Exploration demonstrated disruption of all of the lateral ligaments of the ankle except for the posterior talofibular ligament. thirty-eight Anesthesia years old. with an acute injury. of chronic dislocating VOL. nineteen years old.

SEDLIN clamps and then by having the With patiemit the foot rotate held the rest of the extremity rigidly by the foot piece or externally. itself a rough 15 degrees in has been accepted with as the chronic upper instability. were by was used these as reference a protractor normal tested ankles under varia- talar-tilt A maximum of patients general tion between with anesthesia. injuries than found injuries. In with the anesthetized. it appears ankle. source. in this However. stand. limit of tilt who in a normal tested it is evident the light of ankle. 6-A and measured. Forty of the a talar-tilt a frank was less injured 125 acute angle tear than talar tilt ranged from were treated by surgical 10 degrees were explored. Morewith clinical findings. of tilt of the lateral collateral ligament 15 degrees. angle one described one a general measured by Rubin to roentgenograms and of the dense roentgenograms: congruous corresponding Witten. acutely injured shown tears of a that the injured the greatest accuracy. D. contralateral the right maximum and left ankles. if the while talar-tilt not infallible. their talar-tilt to the has acute been injuries used to make to the of the stress ligaments ankle. the the few patients were talar tilt of stress Whether as yet varied from roentgenograms this method ligament talar 8 to 15 degrees must be of testing However. the tibial talus. 7). It was further noted at operations angle by was exist extent with As if the talarof damage the degree guide. presents possible THE JOURNAL OF BONE AND JOINT SURGERY . roentgenograms of the and anesthetic on the ankle. exploration. The use 6-B) of the found talar-tilt positively may be associated misleading. which can valuable conjunction manifest talar tilt of 15 be employed with 96 per as a clinical aid. Hence. subchondral medial and points measured by bone lateral through The were elevations angle formed 5).of which exhibits talar diagnostic tilt ranging error. No ankles In not the general. from 10 to 15 degrees. Rubin and Witten feel that a talar-tilt a reliable indication of rupture of the fibular cate that approximately degrees or more. in the unanesthetized In the normal ankles only tilt was ankles in 8 degrees. as desired. (Fig. It is my cent over. for of both of five surgical ankles patient patients procedures by a of 125 with with not method patients symptoms normal involving The similar the two of chronic instability given was of twenty-five who were ankles. of these The angle (Fig. interpreted in that the findings clinical findings. ankles with talar tilts of 15 degrees or more have at operation port ion of the fibular rollal eral ligament. the desired rotational has been too limited stress for any will be pro- duced. the not collateral demonstrate was tilts suspected ranging method. The with was drawn on the other of the elevawhich corresponding tions. is certainly angle is interpreted in error will be further minimized. Preliminarily. did that 0 to 70 degrees. The maximum the normal subjects was 10 degrees. study. lead to erroneous negative conclusions not seen any ankles in which a major on the basis of the clinical findings from 20 to 70 degrees when tested angle of less than collateral ligament. In my experience. lines lines Two lines were articular surface. diagnostic 23 degrees is not Their data mdi- 4 per feeling cent that of normal ankles a tool. the tilt of 14 degrees acute. it was of less found that tilt angle (Figs. modification conclusions EXPERIENCE WITH THE DEVICE The device with ankles. Experience with this &IS to its value to be drawn. is not tear of that by did this may I have established. lines as the to the articular surface articular surfaces forms apices drawn.1188 to a ring stand with adjustable internally and ring E.

occasion to My experience of the ankle will stress roentgenography in with a program of primary be the subject of a future report. LECoCQ. with a portable and x-ray thus and machine. J. Also. moderate at the injury. has injuries. quick onset of severe injury. in stress to the forceful must collateral of the in the ligaments foot was light of carried the 5. Failure strate at best. for the repair of acutely plete tears of the lateral stress does occurred. ligament I have attempted to extend incomby application of a marked inversion In view of this experience. Cases LECOCQ. F. J. of the of army injuries of injuries of this personnel of the of device. NO.A DEVICE FOR STRESS INVERSION OR EVERSION 1189 The disability and an indications features time which for stress in the testing patient’s rapid with onset this device such are: as the and to have 1. ligaments. 1952. By the makes of compact. providing movement reduction it possible the x-ray better to the on roentgenograms. clinical marked instability. that I can attribute spasm. diagnosis collateral of of ligaments ankle made possible acute operation were No evidence ligamentous on uniformly out. K. with ligaments the both and and chronic ankles has there Accurate were instability. A practical and effective or eversion at minimum making of rigid to obtain exposure been used in which been device is described for the maintaining of stress the ankle in inversion tus can be constructed it is small while roentgenograms cost and is simple it easy fixation to store the and device are to apply. and and the is an oblique history either uncomfortable manually or with the device. the device enables surgeon or technician who would otherwise a large number acute by use have normal ankles to hold the ankle. procedure marked to 3. pathological Stress even testing view anteroposterior. it the damage that has already usually in routine been associated views of the with ankle on the ankle. ANDERSON. and to the I have employed t ibial-nerve block. In femoral-nerve routinely. 2. Physical ized to the region on weight-bearing. of injury. roentgenograms interpreted REFERENCES 1. that acute are injury very consistent of the gently lateral. and Ankle 34-A: VOL. that stress testing will increase of the evidence deltoid of talar ligament displacement use have Complete roentgenographic so I have of injuries little type.: Recurrent Anterior Subluxation Experimental Study. Oct.. transport eliminates made. Bone and Joint of the Surg. A. A Report of Two 853-860. tenderness and views of physical localpain demonfindings. 2.. 42-A. The device has ankles with 4. Joint. not seem likely tears had this ligaments but have been unable to do so. 3. the been found Attempts acute even that stress to increase injuries though testing increases the tears found lateral inversion be the extent at the time ankles with unsuccessful. The clinical findings findings. Special history. At operations in the complications device. J. with ankle slowly. findings of the of routine changes in an when performed of ecchymosis. demonstrating suture of torn collateral SUMMARY 1 011 . The apparaAt the same time. 7. No of this and in order to eliminate muscle and sciatic-nerve block or peroneal-nerve testing have of acute arisen ruptured collateral injuries. OCTOBER 1960 . severe edema. collateral ligaments. on careful of edema is found ecchymosis involved after questioning to major stress. and an E..

Wochenschr. J.. Bull. and the first and second metacarpala. et M#{233}m. more rare. Chir. there is a fracture-dislocation of the first joint. J. W. 20. Ann Arbor. STEWART. JR. 10.. 22. J. H. Radiol. Edwards. New York State J. KLEIGER. Mi. 2.. DzIoB. MARCEL: Fracture du trapeze. 26: 149-151. Chir. navicular.. 11: 127-140. William Heinemann Ltd. and UUN. ROBERT: Recurrent ubluxation of the Ankle. p. 502-504 Apr. 31. 1936. A. 9. Med.1190 E. C. 54: 2573-2577. M. 8. SENTI MONTAGUT. KLEIGER. 13. 1956. The C. 1946. : Fractures of the of course. Chir. 57: 193-198. STEELE. and WImN. 1921. D. In Reconstruction Surgery of the Extremities.:Injuries to the Ankle. 25: 217-226. : Fracture and Dislocation of the Proximal End of the First Metacarpal Bone and Fracture of the Trapezium. Rass. 29: 74-75. PfrFRIDIS. and JAMES. even WASHINGTON. BONNIN.. 3.A. Med. 23. 1944. 23: 589-594. Cir. M. 15: 83-86. Bone and Ankle... J. 24. 30. 11. San. 1950. Georg Thieme. de Madrid. 1935. 72: 7. 21. CLAYTON. Bone and Joint Surg. RUBIN. Timorr. V. V. Surg. 3. RICHARD. 1956. WATSON-JONES. d’Orthop. ANDERSON. FERNANDo: Fracture du trapeze. : The Chronic Sublu. et M#{233}m. 193: 132-139. Rev. : Suile fratture del trapezio. : Frattura iSOlata di u. J.. Leipsic. 1928. 18. MANDL.n osso del carpo (trapezio). KzLLY. Actas Soc. 29. 55: 1431-1433. Rec. BARNARD: The Diagnosis and Treatment of Traumatic Lateral Ankle Instability. United States Armed 1orces Med. Moaius: The Talar-Tilt Anile and the Fibular Collateral Ligaments. 91 : 692-697. 1938. and isolated This. Surg. ODIN. FELIX: Em Fall von isolierter indirekter Fraktur des Os multangulum majus.. : Frattura isolata del trapezio. Arch. 1955. : Ligamentous Injuries about the Ankle Joint. as indir’ted in the authors’ series. MURRAY: Ankle Injuries. As in two of the authors’ cases. 5. 5: 109-119. 36-A: 825-832. BARNARD: The Mechanism of Ankle Injuries.. The usual roentgenogram of the wrist reveal the greater multangular to be overlapped partially by the lesser multangular. Isolated fractures. J. : El tratamiento de las fracturas de Bennet. I have found it helpful in studying roentgenograms of rather carpometacarpal (Continued on page 1180) THE JOURNAL OF BONE AND JOINT SURGERY . L. indirect CARRUTII JOHN fractures WAGNER. Aid. 1954. J. 51: 1104-1106 1925. ANDR& and Fvius. Bone and Joint Surg. WINTERSTEIN. F.. 17: 843-847. D. 1925. 1939. Vol. : Dislocations. 1934. Acta Radio!. J. DE Moiuzs.M. In the usual case. and Joint Injuries. are rare. K. Bone and Joint Surg. The multangular fracture is usually accompanied bya Bennett type of fracture of the first metacarpal or avulsion of the radial aspect of the second metacarpal base. or both. 28. Beitr. In Campbell’s Operative Orthopaedics. J. pp.. G. Soc. Riv. Nat. 477-482. ALBAN : Grenzen des Normalen und Anfange des Pathologischen im Rontgenbilde. Schweizerische Med. P. Med. hams and Wilkins REGINALD: Fractures Co. Ed. 42-A: 311-326. diagnosis is not always easy. 1955. Ed. H. SCHUM. 32. Deutsche Zeitschr. J. Siciliana. 1916.. MORICONI.. SomumzL ETLENNE: Fracture du trapeze. d’Orthop. J. Mosby Co. 4. A. 1951.. J. M. 1927. July 1954. 0. Nat. PERKINS. London. The American Academy of Orthopaedic Surgeons. z. K. GUSTAV. Clin. 1956. d’Orthop. 1942. W. W. PAvios: Fracture du trapeze. : Operative Treatment of Injury to the Fibular Collateral Ligament of the Ankle. L. and LEC0cQ.. e Terap. Bull.xating 618-621.. 1944. 123: 198-202. Chir. Internaz. 19. Vol. 90: 539-540.. M.. Jan. R.. f. Baltimore. Rev. SEDLIN 2. MEEKISON. Soc.. J.. 426. 38-A: 59-70. 27. LINGUERRI. Omrro. Ed. 26. M. 5. Louis. OLOF: Two Cases of Fracture of the Trapezium (Os Multangulum Majus). 6: 1752-1761. The Wi!- REFERENCES MANAGEMENT OF FRACTURES (Continuedfrom OF THE page GREATER 1118) MULTANGULAR KOaLR. DISCUSSION DR. : Die Frakturformen des Os Metacarpale. Rev. : Weithre Erfahrungen Uber die Bruche der Hand-und Fingerknochen.. With 33-A: Special Reference to Peroneal-Nerve Block as a Diagnostic Am. 12. 25.. A Method for the Determination of Talar Tilt. 1929. C.. J. March 1960. Joint Surg. 6.x: Les fractures du trapeze dans lee traumatismes du poignet. : Diagnostic Criteria of Fibular Collateral Sprain of the Ankle. Klin. St.. MANON. are almost invariably due to direct blows to the wrist. 1924. 4. 1. is because the greater multangular usual injury is of an than of a direct nature. 1956.