92 PENNAL: SUBLUXATION OF THE ANKLE rCan. M. A. J. L[Aug. 1943,vol.49 and showed fibromuscular proliferation, hyalini- zation or complete necrosis (see Fig. 6). SUBLUXATION OF THE ANKLE By Major G. F. Pennal, R.C.A.M.C. SUMMARY AND CONCLUSIONS The nephroselerosis produced by D.C.A. over- TJHE basis of this article is a series of fourteen dosage in the rat is particularly pronounced if cases of subluxation of the ankle encountered the animals are kept on a high NaCl intake. in the past year at Camp Borden Military Hos- Under such conditions D.C.A. causes a pro- pital. The term subluxation is used to define nounced rise in systolic and diastolic blood pres- those injuries resulting in a complete tear of sure, marked diuresis with increased excretion the external lateral ligament of the ankle with of sodium and chloride, proteinuria and clinical a subsequent momentary or recurrent outward signs of severe cardiac decompensation. In some dislocation of the astragalus, unaccompanied by instances death ensues, due to htemorrhagic fracture. lung cedema. The following case history may indicate that The characteristic pathological findings in these injuries are disabling and merit further rats so treated are hypertrophy and capsular consideration. fibrosis of the renal glomeruli with hyaliniza- CASE 12 tion of their tuft capillaries. Fibrosis, hyalini- A man aged 34. Three and one-half months previous zation and even actual necrosis of the arteriolar to consultation, he had slipped and severely wrenched the left ankle whilst running. At that time he was walls is evident not only in the kidney itself- removed to hospital. The radiographs were reported where the vasa afferentia are particularly af- negative anid he was treated in bed with the ankle embed(lded in ice packs and elevated on pillows. the fected-but also in the pancreas and the adrenal subsequent swelling and ecchymosis were quite severe. capsule. In the pancreas these vascular changes In two weeks he was allowed up on crutches, the ankle however remaining moderately swollen and too are frequently accompanied by cedema and pro- painful for weight-bearing. At the end of a further nounced stroma proliferation. The experimental two weeks he gradually began weight-bearing with the aid of crutches. These he discarded for a cane about disease thus produced bears a striking resem- six weeks fromi the date of the accidcent, elastoplast blance to the hypertensive heart disease of renal bandage having been applied about the ankle. At the time of consultation he was still having origin as seen in man. considerable pain and moderate swelling about the joint. He walked with a marked limp, leaning heavily on his The expenses of this investigation were defrayed cane. There was moderate tenderness over the anterior through grants from Frank W. Horner, Ltd. and Gelatin and middle bands of the external lateral ligament. All Products, Ltd., of Canada. The authors are also in- movements were markedly restricted and quite painful, debted to Dr. Erwin Schwenk of the Schering Corpora- especially in foreed inversion. Routine antero-posterior tion of Bloomfield, N.J., for the D.C.A. used in these anld lateral radiographs were negative, except for slight experiments. decalcification. REFERENCES That such a prolonged and severe disability should result from a simple sprain, for that had been the 1. SELYE, H.: Production of nephrosclerosis by overdos- diagnosis, was not reasonable. Further radiographs age with desoxycorticosterone acetate, Canad. M. taken with the foot held in maximum inversion revealed Ass. J., 1942, 47: 515. tilting of the astragalus, thus confirming one 's suspicion 2. SELYE, H. AND STONE, H.: The role of sodium chloride that there had been a comiplete tear of the external in the production of nephrosclerosis by steroids, lateral ligament with subluxation of the astragalus. Proc. Soc. Exper. Biol. a. Med., 1943. 52: 190. Following immobilization in a walking plaster for 3. SELYE, H. AND HALL, C. F.: The pathology of desoxy- three months he completely recovered and returned to corticosterone overdosage in various species, Arch. full duty. Pathol. (in press). 4. FRIEDIMAN, S. M.: A direct plethysmographic method Similar incidents of prolonged disability fol- for determining the blood pressure in the unanaes- lowing "sprains" of the ankle are not uncom- thetized rat, J. Lab. a. Clin. Med., 1941, 27: 240. mon and it is suggested 5. VAN SLYKCE, D. D.: Determination of chlorides in blood that it is often this and tissues, J. Biol. Chemn., 1923, 58: 523. condition of subluxation of the ankle which 6. MCCANcE, R. A. AND SHIPP, H. L.: Colorimetric de- forms the basis of the layman's statement, ''it termination of sodium, Biochenm. J., 1931, 25: 449. may be worse to 7. SELYE, H. AND DOSNE, C.: The action of desoxycorti- sprain an ankle than to break costerone acetate and progesterone on the blood it". and tissue chlorides of normal and adrenalec- Anatomy.-The external lateral tomized animals, Ant. J. Physiol., 1941, 132: 522. ligament of 8. SELYE, H. AND BASSETT, L.: On the effect of desoxy- the ankle is distinctly divided into three bands. corticosterone and testosterone on water and The anterior fasciculus extends from the chloride metabolism, Pr-oc. Soc. Exper. Biol. a. Med., 1940, 45: 272. antero-lateral aspect of the external malleolus 9. SELYE, H., DoSNE, C., BASSETr, L. AND WHITTAKER, J.: to the neck of the astragalus. The middle fasci- On the therapeutic value of adrenal cortical hor- culus, deep to the peroneal mones in traumatic shock and allied conditions, tendons, passes from Canad. M. Ass. J., 1940, 43: 1. the tip of the external malleolus to the peroneal Can. M. A. J. -I Aug. 1943, vol. 49 ] PENNAL: SUBLUXATION OF THE ANKLE 93

tubercle on the outer aspect of the os calcis. lateral ligament, weakened by division into three The posterior fasciculus passes from the postero- bands. Thus it is that in a severe inversion, internal aspect of the external malleolus, to be external rotation strains may result in a com- attached along the posterior articular margin of plete tear of the anterior and middle fasciculi the body of the astragalus. of the outer ligament with momentary subluxa- On the inner side the stability of the joint is tion of the astragalus, unaccompanied by well maintained by the thick single deltoid fracture. ligament extending from the internal malleolus Following dissection of a fresh specimen with to the navicular, to the calcaneo-navicular liga- simple exposure only of the external lateral menit, to the sustentaculum tali, and to the in- ligament and subsequent division of its fasciculi ner side of the astragalus, posteriorly. So strong certain observations were made. is this structure that severe injuries usually Fig. 1 is a radiograph of the joint held in result in a fracture of the internal malleolus. maximum inversion before dissection. It is Complete rupture of tile deltoid ligament is un- noted that there is no tilting of the astragalus. common. Not so in the case of the external Following division of the anterior band only,

7

Fig. 1.-Normal ankle held in full inversion no tilting of the astragalus. Fig. 2.-Ankle in inversion following division of the anterior band of the external lateral ligament only; moderate tilting of the astragalus. Fig. 3.-Ankle in inversion following division of the middle band only; only slight tilting present. Fig. 4.-Ankle in inversion following division of anterior and middle bands; marked subluxa- tion present. Figs. 5a and 5b. Case 4.-Moderate tilting is evident on the left, possibly a complete tear of the anterior band only. The normal ankle in inversion for comparison. Figs. 6a and 6b. Case 6.- Marked subluxation indicating complete tear of the external lateral ligament on the right. Normal ankle on the left held in inversion. Fig. 7. Case 6.-Ankle in foiced inversion followinlg immobilization in walking plaster for ten weeks. Fig. 8. Case 11.-Recurrent subluxation following injury eight years before. Fig. 9. Case 3.-Bilateral recurrent subluxation following severe "sprains"' many years ago, with early secondary arthritic changes. 94 PENNAL: SUBLUXATION OF THE ANKLE Can. M. A. J. [Aug. 1943, vol. 49

Fig. 2 shows slight tilting of the astragalus with tilts and leaves the mortice of the joint on the the foot held in maximum inversion and 450 outer side. However, in minor degrees of sub- plantar flexion. It was noted here that division luxation or where swelling prevents accurate of this band allowed the astragalus to slide palpation such clinical observation may be in- forward a little, coming out of the mortice and accurate. Further, routine radiographs taken tilting, as above, with inversion and flexion. in the antero-posterior and lateral positions Fig. 3 is a film, taken as before, following show no evidence of injury. It is therefore division of the middle band only. There is essential in establishing the diagnosis to have very slight subluxation. an antero-posterior radiograph taken while the Fig. 4 taken following division of both the foot is held strongly in inversion. This ma- anterior and middle fasciculi reveals marked nceuver may be quite painful. Local novocaine subluxation in inversion. It is this complete injection will relieve the pain, overcome the rupture of both bands which is recognized clini- peroneal spasm, and permit full inversion. cally as resulting in subluxation of the ankle. It has been found in a series of normal ankles In operating on old cases of recurrent sub- and in those following simple sprains, that no luxation it has been similarly noted that there matter how strongly the foot is inverted there has been an old complete tear of these bands."2 is no evidence of tilting of the astragalus, Fig. 1. In the dissected specimen with rupture only CLINICAL FEATURES of the anterior fasciculus a minor degree of 1. Simple sprains of the ankle present no tilting was observed, Fig. 2. In practice a serious problem under adequate treatment, and similar minor tilting is occasionally observed are only mentioned in contrast to the more and it is suggested that this may be a mani- severe "sprains", which are really subluxations. festation of a tear of the anterior band only. Simple sprains are recognized when, following Case 4, Fig. 5 is such an example. an inversion strain there is pain, swelling, and When both fasciculi are completely ruptured tenderness, usually quite well localized over the the more common picture of subluxation as in anterior slip of the external lateral ligament. case 5, Fig. 6, is observed in the radiograph A more severe, yet simple, sprain may result taken with the foot held in full inversion. in moderate swelling over both the outer and At the moment of the original injury such inner aspects of the ankle and even slight a subluxation as above takes place and is spon- tenderness over the deltoid ligament also. There taneously reduced, only to recur, however, with is however no instability of the ankle, no rock- each subsequent inversion strain if complete ing of the astragalus and no tilting in the repair of the torn structures is not accomplished. radiograph taken with the foot held in full inversion. TREATMENT The treatment of simple sprains consists in It is readily acknowledged that dislocation of novocaine injection combined with adequate the acromio-clavicular joint requires very firm strapping and early functional activity. prolonged fixation. Subluxation of the ankle 2. Subluxation.-It is suggested that in all with rupture of the external lateral ligament severe sprains of the ankle complete rupture of similarly requires prolonged fixation. Strap- the anterior and middle bands of the external ping alone is inadequate. Immobilization in a lateral ligament,s which has been accempanied walking plaster is essential. The cast, without by a momentary subluxation of the ¢stragalus, padding, is moulded well about the malleoli, should be suspected. making certain that the astragalus is in its nor- The diagnosis is suggested by the severity of mal position and with the foot at a right ankle. the swelling and ecchymosis over the outer side A rubber heel is supplied and walking en- of the joint. Maximum tenderness is elicited couraged at the outset. In two or three weeks, over the upper attachments of the anterior and when the swelling has subsided and the cast has middle bands of the external lateral ligament. become loose, a new cast is applied. The im- There is often a minor degree of swelling and mobilization is continued for a period of ten tenderness over the deltoid ligament, further weeks in all. Fixation for shorter periods, espe- evidence of severe injury. cially in obese persons, is inadequate, resulting By gentle rocking of the ankle in inversion, in incomplete repair and a prolonged disability. it may be possible to detect that the astragalus Just as in the acromio-clavicular joint, it has Aug.1943 vol.49] Aug. 194BOWMAN:3,vol.4~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~9191 BoPROCTOSIGMOIDITIS 951~~~~~~~~~ been demonstrated in the ankle that recurrence SUMMARY of the subluxation will occur with inadequate 1. A series of 14 cases of subluxation of the fixation. ankle, unaccompanied by fracture, resulting If walking is encouraged and functional ac- from a complete tear of the external lateral tivity thus well maintained the degree of stiff- ligament is reported. ness following the removal of the plaster is 2. The anatomy in relation to subluxation and surprisingly slight. It is also felt that the use the observations following division of the com- of a rubber heel in preference to a walking iron ponent parts of the external lateral ligament on permits a more normal gait and a more rapid a fresh specimen are described. return to full activities, with less residual stiff- 3. The method of differential diagnosis be- ness. The results of treatment in this series of tween a subluxation and a simple sprain, by recent subluxations have been quite satisfactory. radiography of the ankle in full inversion, is There has been no residual instability of the outlined. ankle and all the patients have returned to their 4. In all cases of severe "sprain" of the ankle former duties. subluxation of the astragalus should be sus- Recurrent subluxation. - This results from pected. inadequate treatment of the complete tears and 5. The treatment of recent subluxations of the occurs with each inversion strain of the joint. ankle by prolonged immobilization in a walking Repair of the torn ligaments has been incom- plaster has given satisfactory results in this plete or has occurred with lengthening. The series. disability arises from repeated subluxation of I gratefully acknowledge the helpful criticism of the astragalus with recurrent pain and swelling. Lt.-Col. James W. Ross. Participation in sports or strenuous activity is REFERENCES 1. WATSON-JONES, R.: Fractures and Other Bone and thus impossible. The radiograph in Fig. 8 is Joint Injuries, Livingston, Edinburgh, lst ed., 1940. 2. ELMSLIE, R. C.: Ann. Surg., 1934, 100: 364. that from a sergeant-major, showing a marked 3. NILSONNE, H.: J. Bone & Joint ,Surg., 1932, 14: 380. recurrent subluxation resulting from an injury RMSUMEJ eight years ago, which had been treated with Quatorze cas sont rapportes oiu une,subluxation de la strapping. He had carried on only with cheville, sans fracture, fut determin6e par la dechirure complete du ligament lat6ral externe. Les donnees difficulty, complaining of repeated pain and anatomiques de la subluxation et les m6canismes physio- swelling. pathologiques qui entrent en jeu lors de la dechirure du ligament lateral externe sont dUcrits. Le diaginostic dif- The diagnosis is usually easily made by rock- ferentiel avee l'entorse est facilit6 par la radiographie ing the astragalus, as above, and is again con- prise lorsque le pied a et6 placd en rotation"interne forcee. Les entorses serieuses doivent toujogrs faire firmed by radiographs taken with the foot held soupconner la subluxation de 1 'astragale. Le traitement in inversion. consiste dans 1 'immobilisation prolongee dans un ap- pareil platre de marche. JEAN SAUCIER It may be sufficient to supply an outside crooked and elongated heel or an inside iron and T-strap. The other alternative is operative 4.' reconstruction of the external lateral ligament. PROCTOSIGMOIDITIS DUE TO Two procedures have been advocated. ENDAM(EBA HISTOLYTICA The method of Watson-Jones1 is a combined By F. B. Bowman, M.B., F.R.C.P.(C) tenodesis and ligament reconstruction, using the Hamilton, Ont. tendon of the peroneus brevis. It remains at- tached to the base of the fifth metatarsal. The LAST January, 1943, I was consulted in my -detached upper end is threaded through drill office by a man complaining of an intractable holes in the external malleolus and the neck of dysentery. When he entered my office he was the astragalus, replacing very closely the course in such a state of collapse that he had to lie of the torn structures. down on a couch while his history was being The fascial reconstruction described by taken. Every few minutes he was seized with Elmslie,2 using free fascial grafts, is perhaps a severe abdominal cramps and had to go to the more complicated procedure and open to the toilet several times while I was examining him. criticism that eventual stretching of the new At that time I observed the stool in the toilet ligaments under the stress of strenuous activity bowl and saw that it was very soft, nearly all is almost inevitable. mucus, and blood-streaked. He had come from