Injury: the British JournaI of Accident Surgery (1991)Vol. 22/No.
416
bones and has widespread ligamentous attachments to these and other bones of the foot. This is protective but leads to most of its injuries occurring in combination with other midtarsal injuries. When a strong abduction force acts on the forefoot with a relatively fixed hindfoot, the midfoot may be disrupted with avulsion fracture of the tuberosity of the navicular, lateral subluxation of the navicular and an impacted fracture of either of the bones at the calcaneocuboid articulation (Main and Jowett, 1975). There have been reports of 26 such cases in the literature, with the cuboid being fractured in 16 cases and the calcaneum in 10 (Hermel and Gersham-Cohen, 1953; Dewer and Evans 1968; Hunt, 1970; Stark, 1973; Howie et al., 1986; Tountas, 1989). Primary treatment has varied from strapping and plaster cast immobilization to calcaneocuboid and midtarsal fusion. Results have been good in some instances but poor in others, leading to late triple arthrodesis (Main and Jowett, 1975). After reviewing these results, some authors have suggested that open reduction, bone grafting and internal fixation would be the most appropriate primary treatment for these fractures where there is significant displacement at the calcaneocuboid joint (Main and Jowett, 1975; Hillegas, 1976). One case involving the anterior calcaneum has been treated this way (Hunt, 1970). In another case, a dislocated cuboid was reduced and held with Kirschner wires (Drummond and Hastings, 1969). The case presented here had all the features of a forefoot abduction stress injury. Of interest is the fact that the accident causing it appears more trivial than those producing similar effects in other reported cases. There is also the additional fracture of the lateral navicular. This probably arose due to additional longitudinal stress acting along the metatarsals with the forefoot plantar flexed in high heeled shoe.
5
Acknowledgements I wish to express my gratitude
to the following:
Mr B. F. Reeves FRCS, Consultant Orthopaedic Surgeon, St James’s University Hospital, whose patient this was, for his guidance. Mr R. J. Newman ~~hilFRCS, Consultant Orthopaedic Surgeon, St James’s University Hospital, for his helpful suggestions in preparing this manuscript. Mrs Helen Radcliffe who typed the manuscript.
References Dewar F. P. and Evans D. C. (1968) Occult fracture subluxation of the mid-tarsal joint. 1. Bone Joint Szwg. 5OB, 386. Drummond D. S. and Hastings D. E. (1969) Total dislocation of the cuboid bone: report of a case. 1. BoneJoint Surg. 51B, 716. Hermel M. B. and Gersham-Cohen J. (1953) The Nutcracker fracture of the cuboid caused by indirect violence. i&&o/ogy,50, 850. Hillegas R. C. (1976) Injuries to the midfoot: a major cause of industrial morbidity. In: Bateman J. E. (ed.) Foot Science.Philadelphia, London, Toronto: W. B. Saunders Company, 266. Howie C. R., Hooper G. and Hughes S. P. F. (1986) Occult mid-tarsal subluxation. Clin. 0%~. 209,206. Hunt D. D. (1970) Compression fracture of the anterior articular surface of the calcaneus. J. Burz Joint Surg. 52A, 1637. Main M. J. and Jowett R. L. (1975) Injuries of the mid-tarsal joint. J Bane Joint Surg. 5 7B, 89. Stark W. A. (1973) Occult fracture-dislocation of the mid-tarsal joint. Clin. O&q 93,291. Tountas A. A. (1989) Occult fracture-subluxation of the mid-tarsal joint. Clin. Orthop. 243, 195.
Conclusions Displaced fractures at the calcaneocuboid joint should be treated with the aim of preserving the joints for movement and restoring the shape of the bones for structural integrity. The method used here has given good early radiological and functional results. It is recommended as a satisfactory primary treatment of such injuries, with calcaneocuboid fusion reserved for symptomatic cases presenting late.
Paper accepted 5 December
1990.
Requestsfor reprirztsshould be addressed to: Mr A. 0. Ebizie FRCS, Senior Orthopaedic Registrar, Department of Orthopaedics, Leeds General Infirmary, Great George Street, Leeds LSl3EX, UK.
Seat belts and reclining seats R. S. Jeffery and I’. L. Cook Queen Alexandra
Hospital. Portsmouth
and Southampton
Introduction Since 1983 it has been compulsory in Britain to wear a seat belt when travelling in the front passenger seat of a car. Front car seats may be placed in a reclining position for resting when the car is stationary, but the angle at which the seat should be maintained when the car is in motion has not been specified. Many front seat passengers place their seat in 0 1991 Butterworth-Heineman 002~1383/91/050416-02
Ltd
General Hospital, UK a semireclining position for relaxation. There is then a risk of the wearer being hanged by the seat belt in a deceleration accident.
Case report A 19-year-old nanny was sleeping in a reclined front passenger seat when the car was involved in a head-on collision just after
Case reports
417 types invariably unite spontaneously without complication. Separation through the fracture constitutes a traumatic spondylolisthesis (Schneider et al., 1965). Levine and Edwards (1986) classified hangman fractures according to the angulation and displacement. Most injuries are the result of hyperextension and show minimal displacement. A severe neurological deficit is not characteristic and should raise the suspicion of an injury at another level. The more severe categories are sustained when there has been an additional element of flexion leading to wider separation, together with disruption of the C2-3 disc and the posterior ligamentous complex, ultimately with unilateral or bilateral dislocation of the facet joints. Only injuries of this type bear any resemblance to those of judicial hanging. Seat belts. The introduction
of compulsory use of front seat belts resulted in an overall reduction in fatal and serious injuries, but there was an increase in the incidence of characteristic seat belt injuries. Chabannes et al. (1984) describe ten cases of C2 bipedicular fractures in car occupants wearing seat belts. Skold and Voigt (1977) reported post-mortem findings in 34 occupants using seat belts and killed in head-on collisions. Six victims sustained upper cervical injuries when they slid under a seat belt, five using a two-point shoulder belt and one with a lap-shoulder restraint. The lap belt appears to prevent the passenger sliding forward with the risk of the chin catching on the shoulder strap; but this only applies if the seat is upright. We recommend that front seats are not used in the reclining position when the car is in motion.
Acknowledgements We are grateful Figure 1. Lateral radiograph of the upper cervical spine. The hangman fracture shows 3 mm separation together with some angulation and forward malalignment. There is also a fracture of the posterior arch of the altas.
to report department
FRCS for permission to the medical photography General Hospital.
to Mr W. E. G. Griffiths
this case and at Southampton
References midnight. She was woken by the accident and warned the driver not to move her as she thought her neck was broken. She complained of pain in her neck and shoulders and of pain, weakness and paraesthesia in her arms. There was an oblique seat belt bum across her neck from the left ear to the right clavicle. Radiographs revealed a fracture of the pedicles of the axis and the posterior arch of the atlas (F&ml ). She was treated by immobilization with light cervical traction for 6 weeks and then with a hard collar. Grade 4 weakness and paraesthesia affecting the right upper limb resolved gradually over 1 week. She has made a full recovery.
Chabannes J., Colnet G. and Pionchion H. (1984) Fractures bipediculaires de C2 et ceinture de securite. Netlrochinqie 30,
183. Levine A. M. and Edwards C. C. (1986) Treatment of injuries of the Cl-2 complex. Orfkop. C/in. North Am. 17,31. Schneider R. C., Livingstone K. E., Cave A. J. E. et al. (1965) Hangman’s fracture of the cervical spine. 1. Neurosurg. 22, 141. Skold G. and Voigt G. E. (1977) Spinal injuries in belt-wearing car
occupants killed by head-on collisions. Injury 9, 151.
Paper accepted 5 December
1990.
Discussion Hangman
fracture. The hangman fracture is a bilateral traumatic spondylolysis of the pars interarticularis of the axis. All hangman fractures are unstable, but the simple
&quests forreprints should be adAre. fo: Mr R. Jeffery, Orthopaedic Registrar, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK.
416
bones and has widespread ligamentous attachments to these and other bones of the foot. This is protective but leads to most of its injuries occurring in combination with other midtarsal injuries. When a strong abduction force acts on the forefoot with a relatively fixed hindfoot, the midfoot may be disrupted with avulsion fracture of the tuberosity of the navicular, lateral subluxation of the navicular and an impacted fracture of either of the bones at the calcaneocuboid articulation (Main and Jowett, 1975). There have been reports of 26 such cases in the literature, with the cuboid being fractured in 16 cases and the calcaneum in 10 (Hermel and Gersham-Cohen, 1953; Dewer and Evans 1968; Hunt, 1970; Stark, 1973; Howie et al., 1986; Tountas, 1989). Primary treatment has varied from strapping and plaster cast immobilization to calcaneocuboid and midtarsal fusion. Results have been good in some instances but poor in others, leading to late triple arthrodesis (Main and Jowett, 1975). After reviewing these results, some authors have suggested that open reduction, bone grafting and internal fixation would be the most appropriate primary treatment for these fractures where there is significant displacement at the calcaneocuboid joint (Main and Jowett, 1975; Hillegas, 1976). One case involving the anterior calcaneum has been treated this way (Hunt, 1970). In another case, a dislocated cuboid was reduced and held with Kirschner wires (Drummond and Hastings, 1969). The case presented here had all the features of a forefoot abduction stress injury. Of interest is the fact that the accident causing it appears more trivial than those producing similar effects in other reported cases. There is also the additional fracture of the lateral navicular. This probably arose due to additional longitudinal stress acting along the metatarsals with the forefoot plantar flexed in high heeled shoe.
5
Acknowledgements I wish to express my gratitude
to the following:
Mr B. F. Reeves FRCS, Consultant Orthopaedic Surgeon, St James’s University Hospital, whose patient this was, for his guidance. Mr R. J. Newman ~~hilFRCS, Consultant Orthopaedic Surgeon, St James’s University Hospital, for his helpful suggestions in preparing this manuscript. Mrs Helen Radcliffe who typed the manuscript.
References Dewar F. P. and Evans D. C. (1968) Occult fracture subluxation of the mid-tarsal joint. 1. Bone Joint Szwg. 5OB, 386. Drummond D. S. and Hastings D. E. (1969) Total dislocation of the cuboid bone: report of a case. 1. BoneJoint Surg. 51B, 716. Hermel M. B. and Gersham-Cohen J. (1953) The Nutcracker fracture of the cuboid caused by indirect violence. i&&o/ogy,50, 850. Hillegas R. C. (1976) Injuries to the midfoot: a major cause of industrial morbidity. In: Bateman J. E. (ed.) Foot Science.Philadelphia, London, Toronto: W. B. Saunders Company, 266. Howie C. R., Hooper G. and Hughes S. P. F. (1986) Occult mid-tarsal subluxation. Clin. 0%~. 209,206. Hunt D. D. (1970) Compression fracture of the anterior articular surface of the calcaneus. J. Burz Joint Surg. 52A, 1637. Main M. J. and Jowett R. L. (1975) Injuries of the mid-tarsal joint. J Bane Joint Surg. 5 7B, 89. Stark W. A. (1973) Occult fracture-dislocation of the mid-tarsal joint. Clin. O&q 93,291. Tountas A. A. (1989) Occult fracture-subluxation of the mid-tarsal joint. Clin. Orthop. 243, 195.
Conclusions Displaced fractures at the calcaneocuboid joint should be treated with the aim of preserving the joints for movement and restoring the shape of the bones for structural integrity. The method used here has given good early radiological and functional results. It is recommended as a satisfactory primary treatment of such injuries, with calcaneocuboid fusion reserved for symptomatic cases presenting late.
Paper accepted 5 December
1990.
Requestsfor reprirztsshould be addressed to: Mr A. 0. Ebizie FRCS, Senior Orthopaedic Registrar, Department of Orthopaedics, Leeds General Infirmary, Great George Street, Leeds LSl3EX, UK.
Seat belts and reclining seats R. S. Jeffery and I’. L. Cook Queen Alexandra
Hospital. Portsmouth
and Southampton
Introduction Since 1983 it has been compulsory in Britain to wear a seat belt when travelling in the front passenger seat of a car. Front car seats may be placed in a reclining position for resting when the car is stationary, but the angle at which the seat should be maintained when the car is in motion has not been specified. Many front seat passengers place their seat in 0 1991 Butterworth-Heineman 002~1383/91/050416-02
Ltd
General Hospital, UK a semireclining position for relaxation. There is then a risk of the wearer being hanged by the seat belt in a deceleration accident.
Case report A 19-year-old nanny was sleeping in a reclined front passenger seat when the car was involved in a head-on collision just after
Case reports
417 types invariably unite spontaneously without complication. Separation through the fracture constitutes a traumatic spondylolisthesis (Schneider et al., 1965). Levine and Edwards (1986) classified hangman fractures according to the angulation and displacement. Most injuries are the result of hyperextension and show minimal displacement. A severe neurological deficit is not characteristic and should raise the suspicion of an injury at another level. The more severe categories are sustained when there has been an additional element of flexion leading to wider separation, together with disruption of the C2-3 disc and the posterior ligamentous complex, ultimately with unilateral or bilateral dislocation of the facet joints. Only injuries of this type bear any resemblance to those of judicial hanging. Seat belts. The introduction
of compulsory use of front seat belts resulted in an overall reduction in fatal and serious injuries, but there was an increase in the incidence of characteristic seat belt injuries. Chabannes et al. (1984) describe ten cases of C2 bipedicular fractures in car occupants wearing seat belts. Skold and Voigt (1977) reported post-mortem findings in 34 occupants using seat belts and killed in head-on collisions. Six victims sustained upper cervical injuries when they slid under a seat belt, five using a two-point shoulder belt and one with a lap-shoulder restraint. The lap belt appears to prevent the passenger sliding forward with the risk of the chin catching on the shoulder strap; but this only applies if the seat is upright. We recommend that front seats are not used in the reclining position when the car is in motion.
Acknowledgements We are grateful Figure 1. Lateral radiograph of the upper cervical spine. The hangman fracture shows 3 mm separation together with some angulation and forward malalignment. There is also a fracture of the posterior arch of the altas.
to report department
FRCS for permission to the medical photography General Hospital.
to Mr W. E. G. Griffiths
this case and at Southampton
References midnight. She was woken by the accident and warned the driver not to move her as she thought her neck was broken. She complained of pain in her neck and shoulders and of pain, weakness and paraesthesia in her arms. There was an oblique seat belt bum across her neck from the left ear to the right clavicle. Radiographs revealed a fracture of the pedicles of the axis and the posterior arch of the atlas (F&ml ). She was treated by immobilization with light cervical traction for 6 weeks and then with a hard collar. Grade 4 weakness and paraesthesia affecting the right upper limb resolved gradually over 1 week. She has made a full recovery.
Chabannes J., Colnet G. and Pionchion H. (1984) Fractures bipediculaires de C2 et ceinture de securite. Netlrochinqie 30,
183. Levine A. M. and Edwards C. C. (1986) Treatment of injuries of the Cl-2 complex. Orfkop. C/in. North Am. 17,31. Schneider R. C., Livingstone K. E., Cave A. J. E. et al. (1965) Hangman’s fracture of the cervical spine. 1. Neurosurg. 22, 141. Skold G. and Voigt G. E. (1977) Spinal injuries in belt-wearing car
occupants killed by head-on collisions. Injury 9, 151.
Paper accepted 5 December
1990.
Discussion Hangman
fracture. The hangman fracture is a bilateral traumatic spondylolysis of the pars interarticularis of the axis. All hangman fractures are unstable, but the simple
&quests forreprints should be adAre. fo: Mr R. Jeffery, Orthopaedic Registrar, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK.
