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A DANGEROUS TYPE \VILLIAM GISSANE, From The Lisfranc of arterial shown or by the When the wide terminal arterial part damage of soft to this supply of the junction in all Lisfranc of the dorsalis with degrees a dangerous excessive artery or medial however, injury may tibial at further be the ankle During by limbs-that 33 B, is, NO. main ten years recognised FIG. 1 NOVEMBER 1951 of the with foot superimposed. pedis artery (not with and (Fig. is not some second 1), must the foot the degree metatarsals, mean plantar damage arterial arch. in jeopardy. There arterial The shown) the plantar arterial of this fracture and division at its arch is present is not in itself precarious. lateral we rest, of to the cold this division vessel, have conservative bed bones as it joins life fracture displacement the elevation, 4, of in addition last these the associated first injury. When to this injury is added torsion of the main lateral plantar of the posterior tibial artery behind the malleolus, the blood supply of tile foot and or the displacement, degrees great, be the artery site becomes are, always between pedis FOOT Hospital will between dorsalis is confined Displaced foot THE ENGLAND Accident tissues separation of the OF BIRMINGHAM, of the tearing characteristic of the the gross FRACTURE the Birmingham fracture-dislocation damage; division OF fracture of the or both, treated methods packs may three and in be back the pedis associated artery, arterial the posterior injured. Lisfranc for which dorsalis fractures, treatment splints-and with of each very grossly has gross swollen ended in a 535 536 w. below-knee amputation. in consequence believe The of this, to be the last we have anatomy foot so treated reviewed of this GISSANE our It is submitted are displacements and that displacement Evidence artery and that at the was the fourth day the medial malleolus a large In patient the the During the last successful. an attempt, In and so regain been subjected and artery arterial we have not incision is centred exploration of the of the foot, approach the latter blood tied. first metatarsal are their normal position and one of the reasons need for the “key” still to open had also remains the In 2 and to the major surfaces from the 3). the this so the dorsal first far patient held After the the deformity the been the on behind evacuation of vessel. metatarsal space foot. severe and to this tissue tibia! of the first more tissue exposed the of the the vessel; soft posterior was and dangerous fracture bone of displacement, to use for the and will be displacements two patients have major displacements. forces causing foot and surface of the (the other is to release 2 to 4) of the mechanism of the of the easy, a screw the used the tarsal in important reduction internal to fracture is fixed transverse more The was associated or replaced displacements, perhaps but are cuneiform and tension). this vessels medial approach and aspect Through bleeding the allows plantar injury. any reduction This and the of the remarkably (Figs. cuneiform. space of the to “ medial metatarsal aspect reduction “key” plantar and treatment approach dorsal displacements has correct is of his foot by local at soft first by the both through displacements and medially) of dissected from the fracture OPERATION “ in we crushing force, of displacement as the artery death with new metatarsal we believe is the key open reduction is essential metatarsal (Figs. (rotated base by divided the OF bone unrelieved in the a patient first lateral the as high and been reconstruct plantarwards a problem. second cuneiform already ; this why was our on the tibial foot resulted that the of the retrieved reduction bone over is evacuated displaced and, on what Lisfranc to decompression foot in the lesser degrees open reduction we plan aspect being clot Fragments the dorsal which of the received to at least posterior sole TECHNIQUE A medial strain submitted the evidence however, functional emergency dissection approach as the corrected extend injuries submit a better to the known torsion to be in spasm, pedis year cannot can operation dorsum of these and a heavy in a patient found the wound of the forefoot main vessels. vessels At the dorsalis combination displacements to the and from a new to the forefoot and not by direct even in their most extreme forms placed demonstrated injury. haematoma this and after to detailed base are, the skin wound has been caused by a force from within violence. 2) At the examination of the dissected foot it or pronation of the forefoot increased the bone and soft or supination torsion on the damage ankle INJURY closed violence fractures obviously medial rotation and released THE OF complicated and, when they direct crushing lateral rotation open not by a found that tissue the by excessive lateral rotation following reasons : 1) These seldom and was that subjected and injury. ANATOMY caused for the was methods of fixation fix the of the first medial forefoot is supinated and close the gap in arch torn plantar ligaments. If secondary fractures of the metatarsal necks are present these are manipulated to a stable reduction by longitudinal traction on the foot (Fig. 4). Continuous traction to maintain reduction of the fractures of the metatarsal necks was not used. The final result in this patient was a normal foot. In the second patient (Figs. 5 and 6) the the reduction drilled the first of the and more case. “key” displacement a stout silk mattress stable first metatarsal. was suture The again easy, the second used to maintain the rest of the procedure THE JOURNAL and first displaced followed OF metatarsals metatarsals that outlined BONE AND JOINT were over to in the SURGERY A DANGEROUS TYPE OF FRACTURE FIG. FIG. Case 1. Figure of the dorsalis operation)-The before VOL. 33 B, NO. reduction 4, NOVEMBER THE the FIG. fracture with minor in the first space was displacement corrected metatarsal fractures by 4-Final 1951 result. Normal 537 FOOT 2 3 2-Lisfranc pedis artery “key” of Figure OF displacement. At 4 operation rupture found. Figure 3 (radiograph during and the fragments held by a screw, longitudinal traction and pronation. function was regained. 538 W. GISSANE ‘V FIG. Case 2. Figure stable Figure 6-’ first 5 5-()riginal Key bony ‘ ‘ FIG. displacement was displacements Radiograph metatarsal. Six of held taken months by tile degree, silk mattress the forefoot after later minor function of but the dorsalis 6 pedis the was artery suture between second had been pronated and foot was almost normal. ruptured. and more in plaster. metatarsal immobilised DISCUSSION The the purpose more severe twisting of vessels rotation elements of ankle of it, such are long the lower limb particularly when immobilised to such in unpadded to On to in spiral the lower report most common excessive that and the danger and foot. Council is the threaten real damage and is so excessive subjected as to the of Research violence damage of axis the fracture irreparable fracture the stress Lisfranc vessels for (National twisting is to of main around locomotion to the types paper types is responsible rotations this of this life of injuries are rare the of are cause of lower at the twisting reduced by same tibia that matter closed in fibula. rotation of the normal various Very injury, rarely or proximal their division a medico-legal methods main lateral in of cause in to Transverse fractures. of bone foot due gross movements may has is twisting foot and limb site of the damage of the Excessive vessels This the the supply the physiological 1947). limb. blood that supply fractures dangerous the occasions blood limb blood the to suggest or significance, and the limbs are plaster. REFERENCE Fundamental California, Studies in Human Locomotion. Report to the National Research Council, University 1947 THE JOURNAL OF BONE AND JOINT SURGERY of