Avulsed posterior edge of the tibia. Earle's or Volkmann's triangle?

Abstract

The term Volkmann's triangle for the avulsed posterior edge of the tibia in fracture-dislocations of the ankle is incorrect. Volkmann did not publish any articles relating to the posterior edge of the tibia. Credit should go to Henry Earle, who was an outstanding British surgeon of the first half of 19th century. He described avulsion of the posterior edge of the tibia in 1828. In 1823 he also published a monograph entitled Practical observations in surgery in which he described a specially designed bed for the conservative treatment of proximal fractures of the femur.

Full text

746 THE JOURNAL OF BONE AND JOINT SURGERY
Avulsed posterior edge of the tibia
EARLE’S OR VOLKMANN’S TRIANGLE?
J. Bartoníček
From the Charles
University of Prague,
Czech Republic
 J. Bartoníček, MD
Orthopaedic Department of
3rd Medical Faculty, 3.
Charles University,
Srobárova 50, 100 34 Prague
10, Czech Republic.
©2004 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.86B5.
13896 $2.00
J Bone Joint Surg [Br]
2004;86-B:746-50.
Received 1 October 2002;
Accepted 6 October 2003
The term Volkmann’s triangle for the avulsed posterior edge of the tibia in fracture-
dislocations of the ankle is incorrect. Volkmann did not publish any articles relating to the
posterior edge of the tibia. Credit should go to Henry Earle, who was an outstanding British
surgeon of the first half of 19th century. He described avulsion of the posterior edge of the
tibia in 1828. In 1823 he also published a monograph entitled Practical observations in
surgery in which he described a specially designed bed for the conservative treatment of
proximal fractures of the femur.
On the basis of a publication in 1875, the
avulsed posterior edge of the distal tibia, in
cases of fracture-dislocation of the ankle was
termed Volkmann’s triangle
1
although other
authors gave credit for this observation to
Earle in 1828.
2,3
In order to clarify this issue a
study of the original sources was undertaken.
History of the description of avulsion of
the posterior edge
A detailed description of the history of frac-
tures involving the posterior edge of the tibia
can be found in an outstanding study on frac-
ture-dislocations of the ankle by Lauge.
4
The
features of the fractured margin of the articu-
lar surface of the tibia had been described by
Cooper, Earle, Adams, Dupuytren, Mal-
gaigne, Nélaton, Thaon, Gurlt and Richard,
on the basis of post-mortem findings. Lauge
deals in detail with Volkmann’s article
1
and
reprints his line drawings. He states that Volk-
mann described two types, one of which is
avulsion of the anterior edge of the tibia. This
was termed Volkmann’s triangle by all
German authors and in Lauge’s view is incor-
rect. The second type of fracture occurs when
the fracture line passes sagittally and separates
the lateral part of the distal tibia. Lauge did
not agree with Volkmann’s explanation of the
mechanism of this fracture. Furthermore, he
stated that he had not seen this type of frac-
ture.
The first AO monograph of 1965
5
used the
term ‘Earle-Volkmann type’, but in the latest
issue of 1990
6
only Volkmann’s triangle was
mentioned. Weber
2
used Earle’s name for the
avulsed posterior edge of the tibia and he asso-
ciated avulsion of the anterior edge with Volk-
mann.
Hamilton
7
wrote in 1984 that Volkmann
was apparently the first to describe avulsion of
the anterolateral fragment of the distal tibia.
He published Volkmann’s original line draw-
ings which were reprinted from Lauge’s publi-
cation.
4
Kelikian and Kelikian
8
cited one of
Volkmann’s works of 1875,
9
in which there
was a brief description of avulsion of the lat-
eral part of the tibia in the sagittal plane.
Vander Griend, Michelson and Bone
10
in
1991 cited Volkmann’s original work of 1875
1
stating that he was the first to describe avulsion
of the anterolateral edge of the tibia, but that
the description of the mechanism did not cor-
respond to the reality. Avulsion of the posterior
edge in their view was first described by
Cooper followed by Earle.
Zwipp
3
in 1994 was correct when he noted
that avulsion of the posterior edge of the tibia
was first described by Earle and today is
wrongly ascribed to Volkmann. Nevertheless,
later in his text he used the term Volkmann’s
posterior fragment.
Original description by Sir Astley
Cooper (1819)
Cooper’s description of fracture-dislocations
of the ankle is usually dated 1822 when his
work A treatise on dislocations
11
was pub-
lished, but an identical text can be found as
early as 1819.
12
In the part dealing with Dislo-
cation of the ancle-joint he describes “a case of
a very obese lady who fell and .......sprained
her ancle”. The foot dislocated dorsally, but
reduction was not successful. Several years

AVULSED POSTERIOR EDGE OF THE TIBIA 747
VOL. 86-B, No. 5, JULY 2004
later this patient died and Cooper had the opportunity to
study the injured ankle at post-mortem. “The articular sur-
face of the lower part of the tibia was divided into two; the
anterior part was seated upon the os naviculare, the post-
erior upon the astragalus; these two articulatory surfaces
formed at the lower extremity of the bone, had been ren-
dered smooth by friction.” The line drawing (Figs 1 and 2
in his book) as well as the description show, however, that
this was a distal tibial pilon fracture rather than a fracture-
dislocation. In addition, the avulsed edge was not seen on
the line drawing. Credit is also given to Cooper for the
description of the avulsed anterior edge of the tibia. Both
the drawings and the description clearly showed that this
case was not a typical fracture-dislocation, but a compres-
sion fracture of the distal tibia. They showed an avulsed
anterolateral edge of the distal tibia.
Original description by Henry Earle (1828)
13
This description relates to a 53-year-old man who sustained
a severe injury of his right ankle after being knocked off the
pavement by two men. He was admitted to St Bar-
tholomew’s hospital where Earle worked. Examination
showed the following. “There was found to be dislocation
of the tibia forwards, and a comminuted fracture of the fib-
ula. The muscles of the limb were acting spasmodically
with great violence. The dislocation of the tibia was
reduced, and the leg put up in splints. Twelve leeches to be
applied to the part, and cold cloths.” One day later “Mr
Earle desired the splints to be removed that he might exam-
ine the parts. The moment they were taken off, the spas-
modic action of the muscles instantly dislocated the tibia
again. Apply the splints again . . . and administer 35 drops
of the tincture of opium at bed time . . . On the fourth day
after the injury the patient was found to be feverish and
restless. The restlessness became worse on the eighth day
after the injury”, “and he not only again dislocated the
tibia, but forced its extremity through the integuments,
which had become thin and inclined to slough, thus making
it compound. Inflammation and suppuration of the cellular
tissue have taken place. The limb is considerably swelled,
the muscles act spasmodically most powerfully, and the
parts are in an extremely irritable condition. Mr Earle has
made an incision on the outside of the fibula, and also a
small one in front of the tibia, about the junction of its
lower third, through which puss has been evacuated”.
However, the patient at first refused the suggested ampu-
tation, but because of his deterioration finally agreed on the
18th day after injury. It was immediately performed but he
died from sepsis on the 23rd day after the injury.
One day before the patient died, Earle and Stanley dis-
sected the amputated limb. “The tibia dislocated forwards,
with a small portion of its posterior edge fractured and
retained in situ – considered perfectly novel. The fibula
fractured into many pieces, and its extremity driven for-
ward also, upon the astragalus. The internal lateral liga-
ment in a sloughing state, the anterior capsule torn
through, the cartilage of the upper surface of the astragalus
absorbed. The external lateral ligament entire, the outer
side of the fibula denuded of its periosteum for two inches
and half.”
The article is interesting for the contemporary manner of
citation by first stating the name of the hospital followed by
the name of the patient. The names of the authors are not
given, but later in the text there is mention of the attending
surgeons, Earle and his assistant Stanley. Other articles in
this issue of the Lancet are in a similar format. As a result,
authorship can be only judged from the details in the text.
Thus neither Lauge
4
nor Weber
2
mentioned Earle’s chris-
tian name and Kelikian and Kelikian
8
used the wrong initial
“J”. Earle’s correct first name Henry is only noted in subse-
quent publications such as that by Cordasco,
14
in connec-
tion with the conservative treatment of fractures of the neck
of the femur.
Description by Robert Adams (1835-6)
15
In volume I of The cyclopaedia of anatomy and physiology
of man
15
Adams describes in the “Chapter on ankle joint,
abnormal condition”, the case of a 53-year-old woman
who two months previously suffered from “the partial dis-
location forwards of the tibia, combined with a simple frac-
ture of the fibula”. The woman subsequently died and the
post-mortem proved that “the internal malleolus itself had
been broken, and small portion of the back part of the edge
of the articular cavity of the tibia was avulsed”. The
description of this case is of value since, it is supplemented
by two line drawings of the injured limb (medial and lateral
sides) and by two pictures of the bones. The case is very
similar to that of Earle who is mentioned several pages ear-
lier by Adams in connection with the work of Pott. In addi-
tion, Adams discussed the case of a “complete dislocation
of the tibia forwards” treated by Cooper and did not agree
with some details of his description.
Original description by Volkmann of 1875
In the chapter dealing with open fractures of the tibia in his
monograph, Volkmann
1
described the case of a 38-year-old
man who suffered a fracture of the distal tibia and fibula. In
the region of the medial malleolus the skin was perforated
and the wound communicated with the ankle. Because of
infection the distal part of tibia and fibula were resected
and the whole of the talus removed (Fig. 1). Healing took
one year, in the author’s view with a satisfactory functional
result. Examination of the resected joint revealed a fracture
of the fibula three inches proximal to the tip of the lateral
malleolus, avulsion of the tip of the medial malleolus and
avulsion of 7 cm of the lateral aspect of the tibia with the
fracture line passing almost precisely in the sagittal plane.
Volkmann further discussed this type of fracture which
he did not consider had been previously described. He
thought that it had been produced by forced pronation and
abduction resulting in either diastasis of the tibiofibular
joint or, to avulsion of the lateral aspect of the tibia. The

748 J. BARTONÍČEK
THE JOURNAL OF BONE AND JOINT SURGERY
fracture line passed obliquely from the lateral side distally
and medially, in the sagittal plane. Figure 2 shows different
fracture lines and he described two other cases in which he
had resected these wedge-shaped fragments because of
infection. He stated that the skin was often punctured on
the medial side. In a footnote he described a case in which
anterior dislocation of the foot caused avulsion of the ante-
rior edge of the tibia and the fracture line was coronal. He
did not mention whether or not it was combined with
damage to the malleoli.
The drawings and descriptions suggest that Volkmann
primarily reported examples of avulsion of the lateral
aspect of the distal tibia in the sagittal plane. These were
compression (pilon) fractures as demonstrated in his origi-
nal drawings. He did not describe avulsion of the posterior
edge of the tibia, but only avulsion of the anterior edge.
The above-mentioned case of resection of the ankle was
published again by the author in 1875 or 6 (the exact year
can only be deduced) in an article on complicated frac-
tures.
16
The issue of priority
Analysis of the above three descriptions shows that Volk-
mann in no case described a fracture of the posterior edge
of the tibia in fracture-dislocations of the ankle. He men-
tions avulsion of the anterior edge only in two sentences in
a footnote and according to Lauge
4
the priority cannot be
ascribed to him as this type of injury had been previously
described by Cooper, Malgaigne, Richard and Laborie. The
cases which he described were most likely to be pilon frac-
tures. However, he was probably one of the first to operate
successfully on such an injury and the fracture healed after
a year with a good functional result. Although Cooper’s
description is older the author describes only breaking of
the distal tibia into two parts, anterior and posterior. How-
ever, he does not and in fact could not write about other
injuries of the ankle as the autopsy was performed several
years later. Thus the extent of the injury remains unclear. It
might have been a fracture-dislocation of the ankle with a
large posterior edge of tibia, as well as a compression frac-
ture of distal tibia (pilon). In contrast, Earle clearly
describes a typical fracture-dislocation of the ankle. Adams
made a similar description seven years later.
Earle therefore should be credited with the first descrip-
tion of the avulsed posterior edge of the tibia in fracture-
dislocation of the ankle and it should be termed the Earle
triangle.
A biography of Henry Earle
Whereas Richard von Volkmann (1830 to 1889) made
many contributions in surgery and medicine as a whole,
Henry Earle (1789 to 1838) has been almost forgotten and
is mentioned only occasionally in connection with avulsion
of the posterior edge of the tibia
13
although in 1823 he pub-
lished several interesting articles in Practical observations
in surgery,
17
and this book was translated the following
R
R
Fig. 1
Original line drawing of a patient
operated on by Volkmann. Horizon-
tal lines mark the line of resection
of the tibia and fibula (Reprinted
from Volkmann R. Beiträge zur
Chirurgie anschliessend an einen
Bericht über die Thätigkeit der
chirurgischen Universitäts-klinik zu
Halle im Jahre 1873. Leipzig:
Breitkopf und Härtel, 1875).
a
a
b
a
b
*
Fig. 2
Volkmann’s original line drawing
showing a different course of the
fracture lines in a sagittally orien-
tated fracture of the lateral part of the
tibia (Reprinted from Volkmann R.
Beiträge zur Chirurgie anschliessend
an einen Bericht über die Thätigkeit
der chirurgischen Universitäts-klinik
zu Halle im Jahre 1873. Leipzig:
Breitkopf und Härtel, 1875).

AVULSED POSTERIOR EDGE OF THE TIBIA 749
VOL. 86-B, No. 5, JULY 2004
year into German.
18
In it Earle expands on fractures of the
neck of the femur, citing previous authors such as Paré, to
whom he ascribes priority, Desault, Petit, Colles and oth-
ers. For the treatment of such fractures he designed a frac-
ture bed (Fig. 3) to provide maximum comfort for the
patient. Its description and a manual for its use, with
slightly different drawings, was published a year later
(1824) and also reported in the Lancet.
19
Fourteen years
later (1837) the bed was mentioned by Cooper in Principles
and practice of surgery.
20
It was a very sophisticated device
for its time which apart from the comfort for the patient
also allowed treatment of a fracture of the femoral neck in
semiflexion.
In other chapters of the book Earle described fractures of
the olecranon, deformities of the spine and reconstruction
of the urethra. He designed a special bandage for disloca-
tion of the shoulder.
In historical studies dealing with proximal femoral frac-
tures Earle and his bed are mentioned only by Cordasco
14
and his work is not referred to in the outstanding and
detailed description by Peltier
21
nor in Bick’s historical
monograph.
22
A description of Earle’s life may be found in the Diction-
ary of National Biography of 1908.
23
“Henry, Earle... was
born 28 June 1789. His mother was the daughter of Per-
cival Pott, the great surgeon. He became a member of the
College of Surgeons in 1808, and was appointed house sur-
geon at St Bartholomew’s Hospital. In 1811 he began prac-
tice as a surgeon, and attained some notoriety by the
invention of a bed for cases of fracture of the legs. For this
invention he received two prizes from the Society of Arts. In
1833 he was made professor of anatomy and surgery at the
Royal College of Surgeons, and in 1835-7 he was president
of the Royal Medical and Chirurgical Society. Beside twelve
surgical papers Earle published Practical observations in
surgery, London 1823. The frontispiece of this book has a
series of drawings of the bed invented by Earle, and one of
the six essays. This essay led to a controversy with Sir
Astley Cooper as to whether fracture of the neck of the
thigh-bone ever unites. In 1832 Earle published two lec-
tures on the ‘Primary and Secondary Treatment of Burns’.
He died of fever 18 January 1838.”
In this respect it should be noted that the disputes
between Earle and Cooper were acrimonious as docu-
Fig. 3
Diagram of Earle’s fracture bed (Reprinted from Earle H. Practical observations in surgery. London, Underwood 1823).

750 J. BARTONÍČEK
THE JOURNAL OF BONE AND JOINT SURGERY
mented in Earle’s article in the Lancet.
24
The fact that he
was not the only one to argue with Cooper is seen in the
minutes of a meeting of the London Medical Society deal-
ing with Fractures of the neck of the thigh bone.
25
Earle
should not be forgotten not only because he was the first to
describe fracture-dislocation of the ankle with avulsion of
the posterior edge of the tibia, but also because of his orig-
inal contribution to the conservative treatment of fractures
of the proximal femur. He was one of the outstanding Brit-
ish surgeons of the first half of the 19th century.
26
No benefits in any form have been or will be received from any commercial
party related directly or indirectly to the subject of this article.
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