Pott’s Fracture revisited

Percival Pott was born in 1714 in London. His father died when he was young and Pott was raised by his mother and Joseph Wilcocks, the Bishop of Rochester. Pott went to private school and was then apprentice to Edward Nourse at St. Bartholomew’s hospital in London. He became a full surgeon in 1749. In 1756 he was thrown from a horse and had a compound fracture of his ankle. Pott did not allow his ankle to be manipulated and was carried on to hospital where the ankle was stabilized with bandages. Conventual wisdom at the time advised amputation for compound ankle fractures. Bimalleolar ankle fractures with dislocations today are known as “Pott’s fracture.”

Contemporary management of hindfoot fracture dislocations consists of X-rays, CT scans, possible external fixation followed, after the swelling has subsided, with internal fixation. ^, The concept is that good reduction of the talus in the mortise can be achieved and can be kept in place until the injury has healed. This idea is simply mistaken. A talus torn from its attachments and vascularity cannot in an adult heal to produce a stable functional ankle.

The tissue injuries when the talus is dislocated are great. The capsule of the ankle joint is torn, ligaments are disrupted, the cartilage of the talus, distal tibia, subtalar joints and distal talo-fibular joint may be damaged. ^, Imaging of the soft tissue problem is limited to MRI and stress views. Repair would require multiple approaches and is seldom undertaken. What may be possible to heal in a youth is unrealistic in older patients particularly with comorbidities.

The following case report is illustrative:

An eighty-five-year-old man with hypertension, prostate cancer, and lumbar spondylosis sustained an open right bimalleolar fracture with tibio-talar dislocation in a car accident.

His initial treatment was urgent reduction ( Figs. 1 and 2 ) and application of an external fixator ( Fig. 3 ).

Next he underwent open reduction internal fixation with syndesmotic stabilization ( Fig. 4 post fixation). His postoperative course was complicated by medial and lateral ankle wounds, infection and progressive mechanical instability with widening of the mortise ( Fig. 5 ). Given the combination of infection, structural collapse and failure with conventional fixation he underwent salvage tibiotalocalcaneal stabilization with an antibiotic coated intramedullary nail ( Fig. 6 ).