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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

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 surgeons 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

DEVICE

FOR

STRESS

ixvsmox

OR

EVERSIOX

1185

Lateral view of the taming ring: an(l e =

foot

piece:

heel

flange;

clamping

screw;

connecting

rod:

(I

rope

clamp.

FIG.

loot
and
VOL. C
=

liiece

viewed

fr
rod.

ni ahove.

it Ii anchor

strap

attached:

(1

metaimiing

ring;

rope

clamp;

connecting
No. 7,

42-A,

OTOBEIt

1960

1186

E.

D.

SEDLIN

FIG.

FIG.

4
screw.

Fig. Vig.

3: Foot 4: Lower

piece as extremity

viewed

with device

from

below:

applied

for

turret
stress

clamp
inversion

and

clamping

roentgenogram.

piece

are

squeezed

against

the

foot,
The

amid the

screws

of the

turret

clamps

are

tight-

ened against the cominecting rods. just al)ove the knee, with the two

ropes

anchoring on either

strap is applied around the thigh the medial or lateral side, dependThe adjustment the foot in equinus
or iii neutral position

ing omi whether inversiomi or eversiomi stress is to I)e applied. 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, the


are sufficiently

of the calcaneofibular ligament. To ropes are pulled through the tapered


taut
.

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, the device remains imi position, take place because the curves of the flanges
was

rigidly.

amoumit

amount

needed

of stress to be applied to just cause discomfort,


was

determined

in the

normal

and to The

in the the

anesthetized, to the applied that by

acutely point was

ankle as the amount of stress sistance to further inversion mined quantitatively, of stress was used
and it is thought

needed felt.

invert amount taken were

ankle of stress

where renot deter-

in
that

nor were precautions all ankles. All tests


reasonably

to assure performed
testing

the same amount three individuals,


were used

comparable

conditions

throughout. Both
roentgenograms

an from
no

anteroposterior
were

and obtained.
in

an oblique Comparison mortise determined. long axis

or mortise view were of the measurements roentgenograms Since of the foot, 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,

perpendicular

is naturally

in the is lying
most

appropriate supine.
part.

position for For this reason,

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. is accomplished

is a simiple procedure it has l)een achieved. external by or internal fixing


THE

requires If desired, as of the


AND JOINT

about one the device the foot roentpiece

rotation bars
BONE

the
JOURNAL

cross
OF

SURGERY

A DEVICE

FOR

STRESS

iNVERSION

OR

EVERSJON

1187

Fio. 5

FIG.

6-A

Fig. 5: Stress inversion roentgenogram of a recruit, twenty-two years old, with an acute injury. Femoral-nerve and sciatic-nerve block was used. Exploration demonstrated disruption of all of the lateral ligaments of the ankle except for the posterior talofibular ligament. Fig. 6-A: Stress inversion roentgenogram of a recruit, nineteen years old, with an acute injury. Femoral-nerve and sciatic-nerve block was used. Exploration demonstrated a tear of the anterior talofibular ligament and the lateral capsule and an incomplete tear of the calcaneofibular ligament.

FIG.

6-B
roentgenogram roentgenogram
was of

FIG.

Fig. Fig.

6-B: Stress 7: Stress

inversion inversion

the
a

contralateral
sergeant,

ankle.
thirty-eight

Anesthesia
years old,

was
with

not
:i

used.

of

chronic

dislocating
VOL.
42-A.

ankle.
NO.

Anesthesia
1960

not

used.

The

tilt

of the

contralateral

ankle

was

nil.

7. OCTOBER

1188 to a ring stand with adjustable internally and ring

E.

D.

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, as desired. stand, the desired rotational has been too limited

stress for any

will

be pro-

duced. Experience with this &IS to its value to be drawn.

modification

conclusions

EXPERIENCE

WITH

THE

DEVICE

The

device with ankles, their talar-tilt to the

has acute

been injuries

used

to make to the of the

stress ligaments ankle,

roentgenograms of the and anesthetic on the ankle, 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. angle one described


one

a general measured by Rubin


to

roentgenograms

and of the dense

roentgenograms: congruous

corresponding

Witten. the tibial talus. lines lines

Two lines were articular surface; The with


was

drawn on the other of the elevawhich

corresponding tions. lines


as the

to the articular surface articular surfaces forms apices drawn. of these The
angle (Fig.

subchondral medial and points measured by

bone lateral through

The were

elevations angle formed


5).

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, the

tilt of 14 degrees acute, contralateral the right maximum and left ankles, injuries than

found injuries.

in the unanesthetized In the normal ankles


only

tilt was ankles in

8 degrees.

The

maximum

the

normal

subjects

was

10 degrees.

In with

the anesthetized, 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. did that

0 to 70 degrees. exploration. No ankles In not the general, it


was

of less

found that tilt angle (Figs. of tilt

of the lateral collateral ligament 15 degrees. It was further noted at operations


angle by
was

exist extent
with As

if the talarof damage


the degree guide,

6-A and measured.


The use

6-B)
of the

found
talar-tilt

positively may be

associated misleading.

itself

a rough

15 degrees
in

has

been

accepted with

as the chronic

upper instability,

limit

of tilt who

in a normal tested it is evident the light of

ankle. in this

However, study, 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,

(Fig. 7). Hence, interpreted in

that the findings clinical findings. is not tear of that by did this

may
I have

established.

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.

the
not

collateral
demonstrate

was tilts

suspected ranging

method. Rubin and Witten feel that a talar-tilt a reliable indication of rupture of the fibular cate that approximately degrees or more. It is my cent over,
diagnostic

23 degrees is not Their data mdi-

4 per feeling

cent that

of normal ankles a tool, which can valuable conjunction

manifest talar tilt of 15 be employed with 96 per as a clinical aid. Morewith clinical findings, acutely injured shown tears of a that the injured the greatest

accuracy, if the

while talar-tilt

not infallible, is certainly angle is interpreted in

error will be further minimized. In my experience, ankles with talar tilts of 15 degrees or more have at operation port ion of the fibular rollal eral ligament. Preliminarily, it appears

ankle,
source.of

which

exhibits

talar diagnostic

tilt

ranging error.

from

10 to 15 degrees,

presents

possible

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

DEVICE

FOR

STRESS

INVERSION

OR

EVERSION

1189

The disability
and an

indications features time


which

for

stress in the

testing patients rapid

with onset

this

device such

are: as the and


to have

1. Special

history,

quick

onset

of severe injury.
moderate

at the
injury,

of injury,
on careful

of edema
is found

ecchymosis
involved

after

questioning

to major stress; 2. Physical ized to the region on weight-bearing;

findings of the of routine


changes in an when performed

of ecchymosis, collateral ligaments,

severe

edema, clinical

marked instability,

tenderness and views


of physical

localpain demonfindings. procedure

marked to

3. Failure
strate at best, pathological Stress even testing view

anteroposterior,
that acute are injury very consistent of the gently

lateral,
with ankle slowly, and

and
the is an

oblique
history either uncomfortable

manually

or with

the

device. In femoral-nerve routinely, No

of this and in order to eliminate muscle and sciatic-nerve block or peroneal-nerve testing have of acute arisen ruptured collateral injuries. that I can attribute

spasm, and to the

I have employed t ibial-nerve block, At operations

in the complications

device.

for the repair of acutely plete tears of the lateral stress does
occurred.

ligaments, ligament

I have attempted to extend incomby application of a marked inversion In view of this experience, it the damage that has already usually in routine been associated views of the with ankle

on the ankle, not seem likely tears had this ligaments

but have been unable to do so. that stress testing will increase of the evidence deltoid of talar ligament displacement use have

Complete roentgenographic so I have


of injuries

little type.

occasion to My experience of the ankle will

stress roentgenography in with a program of primary be the subject of a future report.

demonstrating suture of torn

collateral

SUMMARY

1
011

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. transport eliminates

made. The apparaAt the same time, with a portable and

x-ray thus

and machine. 2. By the makes


of

compact, providing

movement

reduction

it possible the x-ray

better to the on

roentgenograms. Also, the device enables surgeon or technician who would otherwise a large number acute
by use

have normal ankles

to hold the ankle. 3. The device has ankles with


4. of the

of army injuries of injuries


of this

personnel of the of
device.

with ligaments the

both and

and chronic

ankles
has

there Accurate

were

instability. has injuries.

diagnosis

collateral of of

ligaments

ankle

made

possible

acute operation
were

No evidence ligamentous on uniformly out. 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, in


stress

to the forceful
must

collateral of the in the

ligaments foot was light of

carried the

5. The clinical

findings findings.

roentgenograms

interpreted

REFERENCES 1. ANDERSON,

K. J.;

LECoCQ,

J. F.;

and

Ankle 34-A:
VOL. 42-A,

Joint. A Report of Two 853-860, Oct. 1952.


NO. 7,

Cases

LECOCQ, and an

E. A.: Recurrent Anterior Subluxation Experimental Study. J. Bone and Joint

of

the

Surg.,

OCTOBER

1960

1190

E.

D.

SEDLIN

2. ANDERSON, K. J., and LEC0cQ, J. F. : Operative Treatment of Injury to the Fibular Collateral Ligament of the Ankle. J. Bone and Joint Surg., 36-A: 825-832, July 1954. 3. BONNIN, J. G.:Injuries to the Ankle. London, William Heinemann Ltd., 1950. 4. CLAYTON, M. L.; Timorr, A. W.; and UUN, ROBERT: Recurrent ubluxation of the Ankle.

With
33-A:

Special

Reference

to Peroneal-Nerve

Block as a Diagnostic
Am.

Aid. J. Bone and


Ankle.

Joint

Surg.,

502-504 Apr. 1951. 5. DzIoB, J. M. : Ligamentous Injuries about the Ankle Joint. 6. KzLLY, J. H., and JAMES, J. M. : The Chronic Sublu.xating
618-621, 1956.

J. Surg. 91 : 692-697, 1956. A.M.A. Arch. Surg., 72:

7. KLEIGER, BARNARD: The Diagnosis and Treatment of Traumatic Lateral Ankle Instability. New York State J. Med., 54: 2573-2577, 1954. 8. KLEIGER, BARNARD: The Mechanism of Ankle Injuries. J. Bone and Joint Surg., 38-A: 59-70, Jan. 1956. 9. MEEKISON, MURRAY: Ankle Injuries. In Reconstruction Surgery of the Extremities, The American Academy of Orthopaedic Surgeons, 1944, pp. 477-482. Ann Arbor, J. W. Edwards, 1944. 10. RUBIN, GUSTAV, and WImN, Moaius: The Talar-Tilt Anile and the Fibular Collateral Ligaments. A Method for the Determination of Talar Tilt. J. Bone and Joint Surg., 42-A: 311-326, March 1960. 11. STEELE, M. K. JR. : Diagnostic Criteria of Fibular Collateral Sprain of the Ankle. United States Armed 1orces Med. J., 6: 1752-1761, 1955. 12. STEWART, M. J. : Dislocations. In Campbells Operative Orthopaedics. Ed. 3. Vol. 1, p. 426. St. Louis, The C. V. Mosby Co., 1956.
13. WATSON-JONES, hams and Wilkins REGINALD: Fractures Co., 1955. and Joint Injuries. Ed. 4. Vol. 2. Baltimore, The Wi!-

REFERENCES MANAGEMENT OF FRACTURES (Continuedfrom OF THE page GREATER 1118)


MULTANGULAR

KOaLR, ALBAN : Grenzen des Normalen und Anfange des Pathologischen im Rontgenbilde. Ed. 5. Leipsic, Georg Thieme, 1928. 19. LINGUERRI, R. : Frattura iSOlata di u.n osso del carpo (trapezio). Radiol. Med., 29: 74-75, 1942. 20. MANDL, FELIX: Em Fall von isolierter indirekter Fraktur des Os multangulum majus. Beitr. z. Klin. Chir., 123: 198-202, 1921. 21. MANON, Mi.x: Les fractures du trapeze dans lee traumatismes du poignet. Rev. dOrthop., 11: 127-140, 1924. 22. DE Moiuzs, FERNANDo: Fracture du trapeze. Rev. dOrthop., 25: 217-226, 1938. 23. MORICONI, L. : Frattura isolata del trapezio. Rass. Internaz. Clin. e Terap., 17: 843-847, 1936. 24. ODIN, OLOF: Two Cases of Fracture of the Trapezium (Os Multangulum Majus). Acta Radio!., 15: 83-86, 1934. 25. Omrro, P. : Suile fratture del trapezio. Riv. San. Siciliana, 23: 589-594, 1935. 26. PERKINS, C. W. : Fracture and Dislocation of the Proximal End of the First Metacarpal Bone and Fracture of the Trapezium. Med. Rec., 90: 539-540, 1916. 27. PfrFRIDIS, PAvios: Fracture du trapeze. Rev. dOrthop., 26: 149-151, 1939. 28. RICHARD, ANDR& and Fvius, MARCEL: Fracture du trapeze. Bull. et M#{233}m. Soc. Nat. Chir., 51: 1104-1106 1925. 29. SCHUM, H. : Weithre Erfahrungen Uber die Bruche der Hand-und Fingerknochen. Deutsche Zeitschr. f. Chir., 193: 132-139, 1925. 30. SENTI MONTAGUT, V. : El tratamiento de las fracturas de Bennet. Actas Soc. Cir. de Madrid, 5: 109-119, 1946. 31. SomumzL ETLENNE: Fracture du trapeze. Bull. et M#{233}m. Soc. Nat. Chir., 55: 1431-1433, 1929. 32. WINTERSTEIN, 0. : Die Frakturformen des Os Metacarpale. Schweizerische Med. Wochenschr., 57: 193-198, 1927. 18. DISCUSSION
DR. are rare, indirect CARRUTII JOHN
fractures

WAGNER, even

WASHINGTON, more rare.

and isolated

This,

D. C. : Fractures of the of course, is because the

greater

multangular

usual

injury

is of an

than of a direct nature. In the usual case, there is a fracture-dislocation of the first joint. 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. Isolated fractures, as indirted in the authors series, are almost invariably due to direct blows to the wrist. As in two of the authors cases, diagnosis is not always easy. The usual roentgenogram of the wrist reveal the greater multangular to be overlapped partially by the lesser multangular, navicular, and the first and second metacarpala. I have found it helpful in studying roentgenograms of rather carpometacarpal

(Continued

on page 1180)
THE JOURNAL OF BONE AND JOINT SURGERY