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Ankle Fracture Eponyms

The document discusses several types of ankle fractures that are historically known by eponyms named after the physicians who first described them. It provides biographical information about Percivall Pott and Guillaume Dupuytren, and defines a Pott fracture and a Dupuytren fracture.

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0% found this document useful (0 votes)
279 views7 pages

Ankle Fracture Eponyms

The document discusses several types of ankle fractures that are historically known by eponyms named after the physicians who first described them. It provides biographical information about Percivall Pott and Guillaume Dupuytren, and defines a Pott fracture and a Dupuytren fracture.

Uploaded by

yarianna2
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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e198(1)

C OPYRIGHT 2013

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

the

Orthopaedic
forum
Ankle Fracture Eponyms
M.P. Somford, MD, J.I. Wiegerinck, MD, D. Hoornenborg, MD, and M.P.J. van den Bekerom, MD
The acute ankle fracture has often been cited as one of the most
commonly treated musculoskeletal injuries. As such, considerable research has been conducted, along with many clinical
studies, aiming to evaluate conservative versus surgical management, as well as radiographic classifications and long-term
outcomes. Several types of ankle fractures are known historically by their eponyms. Eponyms are frequently used in orthopaedic surgery to denominate fractures, fracture-dislocations,
and classifications, which are most commonly named after the
physicians who first described them.
In 2007, a debate entitled Should Eponyms Be Abandoned? evoked strong responses both in favor and against the
use of medical eponyms, and added interesting insights into
their current use1,2. The opponents of the use of eponyms in
the medical literature recommend abandoning them because
they lack accuracy, lead to confusion, and hamper scientific
discussion in a globalized world.1 Some disadvantages are obvious. Some eponyms do not refer to the correct person but to a
later researcher who made the same discovery. For example John
Langdon Down did not discover the syndrome mongolism,
but rather coined the term, which was later changed to Down
syndrome because the former name was considered racist. Additionally, the person behind a medical eponym might have been
involved in crimes against humanity, as was the case with Hans
Conrad Julius Reiter in Nazi Germany. Other disadvantages are
subtle. For example, pronunciation and spelling may be incorrect. Foreign eponyms that have diacritics (e.g., acute or grave
accents) are often misspelled or mispronounced. Sometimes it is

hard to establish the exact spelling when you hear someone using
an eponym. Finally, an eponymous fracture or classification system is only clinically relevant when it has consequences for
treatment or when it influences prognosis. This has resulted in
abandoning the scientific use of many of eponyms.
In contrast to these opinions, proponents advocate retention of eponyms because they are often practical and a
form of medical shorthand, and bring color to medicine
and they embed medical traditions and culture in our history.2
Appropriate and uniform use of nomenclature regarding an
ankle fracture, for example, is vital for the care of patients who
sustain one since it is used for identification, classification, and
retrieval of information from databases and therefore often
used by health-care providers when discussing treatment3,4.
The aim of this uniformity is to provide a flexible, practical,
and scientifically acceptable term to describe a fracture and
ensure clarity when discussing it. This promotes communication among colleagues, facilitates consistency in spelling, and
avoids confusion in both the basic and clinical sciences5.
The objective of this article is to summarize and describe
the most commonly used ankle fracture eponyms (Fig. 1). The
first goal is to give some information about the people whose
names are connected with these fractures, and the second goal
is to provide a clear definition of the various ankle fractures.
Because the history behind the eponym often remains obscure
or unknown to the user, it is hoped that this report will serve as
a resource and will aid in the preservation of orthopaedic history and prevent confusion when these eponyms are used.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work,
with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has
had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in
this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2013;95:e198(1-7)

http://dx.doi.org/10.2106/JBJS.M.00198

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A N K L E F R AC T U R E E P O N Y M S

Fig. 1

Overview of eponyms used with ankle fractures.

Pott Fracture
Percivall Pott was born on January 6, 1714 in London on the
present site of the Bank of England. Although educated to
become a clergyman, he was apprenticed to become a surgeon
at St. Bartholomews Hospital in 1729, and he became an assistant surgeon in 1745. In 1749, he became a full surgeon, and
he remained in this position until his retirement in 1787. In his
own words, he served the institution as a boy and a man.6 In
1756, he was thrown off of his horse while riding to the Lock
Hospital. He sustained a compound fracture of the ankle. If not
for his mentor, Edward Nourse, the leg would have been amputated, a common practice in those days. Instead, the fracture
was reduced, and it healed over time. After a lengthy recuperation from the fracture, Pott wrote surgical textbooks; in 1768,
he described the fracture that he himself had sustained with the
following classic description:
When the fibula breaks within two or three inches of its
lower extremity, the inferior fractured end falls inwards towards
the tibia, that extremity of the bone which forms the outer ankle
is turned somewhat outward and upward, and the tibia having
lost its proper support is forced off from the astragalus inwards,
by which means the weak bursal or common ligament of the
joint is violently stretched if not torn, and the strong ones which
fasten the tibia to the astragalus and os calcis are always lacerated,
thus producing a perfect fracture and a partial dislocation to

which is sometimes added a wound in the integuments. All of


the tendons which pass behind or under, or are attached to the
extremities of the tibia and fibula or os calcis, have their natural
direction so altered that they all contribute to the distortion of
the foot and that by turning it outward and upward.
It is extremely troublesome to put to rights, still more so
to keep it in order, and unless managed with address and skill is
very frequently productive of lameness and deformity ever after, but if the position of the limb be changed, if by laying it on
the outside with the knee moderately bent, the muscles forming the calf of the leg and those which pass behind the fibula
and under the os calcis are all put in a state of relaxation and
non-resistance, all this difficulty and trouble do in general vanish immediately, the foot may easily be placed right, the joint
reduced, and by maintaining the same disposition of the limb
everything will in general succeed very happily.7
Pott was the first to describe environmental influences on
disease: he linked chimney sweeping with the development of
scrotal cancer. One of his pupils was John Hunter, who later
became one of the greatest anatomists of the time and the
founder of experimental pathology in England. After making
a house call in foul weather, Pott fell ill. Feeling he was nearing
his end, he stated, My lamp is almost extinguished: I hope it
has burned for the benefit of others.6 He died of pneumonia
on December 22, 17886,8,9.

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A N K L E F R AC T U R E E P O N Y M S

A Pott fracture is a fracture-dislocation of the ankle, involving a fracture of the fibula, disruption of the deltoid ligaments, and an intact tibiofibular ligament. This results in a
lateral displacement of the talus.
Dupuytren Fracture
Guillaume Dupuytren (Fig. 2) was born the son of an impoverished advocate in Pierre-Buffie` re, France, on October 5, 1777.
Although he wanted a career in the army, his father convinced
him to get into the medical profession. He studied in Paris beginning at age sixteen. It is said that he was so impoverished that
he took the fat of the cadavers used for dissection education to
make oil for his lamp. At the age of eighteen, he became prosector at his medical school and was in charge of all autopsies. In
1803, he acquired his doctorate from the University of Paris,
which was delayed because of the suppression of medical schools
by the revolutionary government. In 1808, he became a surgeon

at the Hotel-Dieu
in Paris. Beginning in 1815, he held the position of chief of surgery there for more than twenty years. His
merciless, obsessive-compulsive personality and absolute perfectionism gained him the nicknames Brigand dHo tel-Dieu,
Napoleon of surgery, and first among surgeons, last among
men.10 However, he was a great lecturer with an amazing memory for case histories, medical studies, and details, making him
an outstanding diagnostician and teacher.
Because Dupuytren loathed writing, his students published his lectures and investigations. These reports cover the
entire surgical field of that time. In his prime, Dupuytren saw
10,000 patients a year. The money that he acquired was once
used to help Charles X, who was dethroned and in need of
money. A gift of one million francs came with the notion that
Charles could receive another million for his daughter and a
third for his old age, but the king declined. Dupuytren was made
a baron by Louis XVIII and was also appointed his personal
surgeon. In addition, he was the first surgeon to Charles X.

Fig. 2

Fig. 3

Fig. 2 Guillaume Dupuytren. (Reproduced, with modification, from:


Wikipedia, The Free Encyclopedia, http://en.wikipedia.org/w/
index.php?title=Guillaume_Dupuytren&oldid=553454001. [Public domain] Accessed 2013 Sept 28.) Fig. 3 Richard von Volkmann. (Reproduced, with modification, with permission from Peter Hoffman, Editor of
www.rond1900.nl.)

Fig. 4

David Marsh Bosworth. (Reproduced, with modification, from: David Marsh


Bosworth, 1897-1979 [obituary]. J Bone Joint Surg Am. 1980;Apr
62[3]:488.)

In 1833, Dupuytren had a stroke while giving a lecture,


forcing him to retire from the Ho tel-Dieu in 1834. He died in
Paris on February 8, 1935. He left 200,000 francs to the medical
faculty; they used it to found the Muse e Dupuytren, which still
exists today10,11.
A Dupuytren fracture of the fibula is located 1 inch above
the syndesmosis (low Dupuytren) or 2.5 to 3 inches above the
syndesmosis (high Dupuytren)11,12.
Volkmann Triangle
Richard von Volkmann (Fig. 3) was born in Leipzig, Germany,
on August 17, 1830. After attending medical schools in Giessen,
Halle, and Berlin, he started working as a professor of surgery at
the University of Halle in 1867. Besides his contributions to the
medical literature, he also wrote fairy tales and poems, illustrated by his son, under the pen name of Richard Leander. In
1881, he described the contraction of fingers after a compression injury, now called a Volkmann contracture. He died in
Jena, Germany, on November 28, 1889.
An avulsion of the posterior lateral edge of the distal part
of the tibia or a posterior malleolus fracture, in the case of a
fracture-dislocation of the ankle, is called a Volkmann triangle. However, this eponym is debated because, in his original
article, Volkmann primarily described examples of an avulsion
of the lateral aspect of the distal part of the tibia in the sagittal
plane. The first description of a case of an avulsion fracture of
the posterior part of the tibia actually was accredited to Henry
Earle in 182813-15.
Bosworth Fracture
Professor David Marsh Bosworth (Fig. 4) was born the son of a
minister in New York City on January 23, 1897. Bosworth
graduated cum laude from the Medical School of the University
of Vermont in 1921. In 1926, he started his residency in orthopaedic surgery at the New York Orthopaedic Hospital. In 1968,
he received a Japanese award, The Second Order of the Sacred
Treasure, for his contributions to orthopaedic surgery; he is
the only foreign recipient of this award. His most important

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Fig. 5

A N K L E F R AC T U R E E P O N Y M S

Fig. 6

Fig. 5 Jacques-Gilles Maisonneuve. (Reproduced, with modification, from:


Wikipedia, The Free Encyclopedia, http://en.wikipedia.org/w/index.
php?title=Jules_Germain_Fran%C3%A7ois_Maisonneuve&oldid=
543612032. [Public domain] Accessed 2013 Sept 28.) Fig. 6 Leon
Clement Le Fort. (Reproduced, with modification, from: Wikipedia, The Free
Encyclopedia, http://en.wikipedia.org/wiki/Leon_Clement_Le_Fort.
[Public domain] Accessed 2013 Sept 28.)

medical contribution was the introduction of streptomycin for


the treatment of bone and joint tuberculosis.
A dedicated surgeon, after working in New York during
the week, Bosworth flew his own plane to Vermont to teach and
operate on the weekend. His evenings and Sundays were filled
with photography and writing. All of his publications featured
his own photographs. He remained in active practice until the
age of eighty-two; he died on July 11, 197916.
Described by Bosworth in 1947, a fracture of the distal part
of the fibula with an associated fixed posterior dislocation of the
proximal fibular fragment, which becomes trapped behind the
posterior tibial tubercle, is called a Bosworth fracture. This is a
variation on the entrapment of an intact fibula behind the tibia,
which was first described by Ashhurst and Bromer in 192217,18.
Maisonneuve Fracture
Jacques-Gilles Maisonneuve (Fig. 5) was born in Nantes, France,
on November 10, 1809. He studied in Nantes and later became a
surgical student under Dupuytren in Paris. He was the first to
describe external rotation as the reason for a specific type of
ankle fracture. He died in Missilac, France, on April 9, 189719.
A fracture of the proximal third of the fibula associated
with a medial ankle injury is called a Maisonneuve fracture.
With use of cadaver studies, Maisonneuve described how an
external rotation force applied to the foot could result in a
fracture of the proximal third of the fibula19. In the case of an
isolated medial malleolar fracture or medial ankle ligament
rupture, it is now common practice to exclude a proximal fibular fracture, which is indicative of a rupture of the syndesmosis and the entire interosseous membrane20.
Le Fort-Wagstaffe Fracture
Le on Cle ment Le Fort (Fig. 6) was born on December 5, 1829. He
studied medicine in Paris, and after serving for two years as a

volunteer in the French army during the Italian War, he became


prosector of the faculty in Paris. In 1870, he again joined the army
to become the head of a voluntary field hospital in Metz during the
Franco-Prussian War. In 1873, he became a professor of operative
surgery at the medical faculty. He died on October 19, 1893.
Le Fort discovered and described the direct communications between the bronchial and pulmonary vessels. He advocated the principles of asepsis before scientific bacteriology was
developed. A classification of facial fractures was described by
his nephew and godson, Rene Le Fort (1869-1951)21.
William Warwick Wagstaffe (Fig. 7), the son of a surgeon,
was born in London in 1843. He worked at St. Thomas Hospital. He became a bachelor of medicine in 1867 at the University of London and obtained a fellowship in the Royal
College of Surgeons in 1868. He was struck down by an obscure
nervous malady, which slowly but steadily removed all his ability for physical activity22. He was lucid and fluent as a lecturer
and demonstrator, holding the attention of the class, which was
always orderly and well behaved at a time when the lecture
room occasionally became quite rowdy. He died on January
22, 1910. At that time, he was a consulting surgeon to the local
hospital in Sevenoaks. He was praised in his obituary: no word
of complaint leaving his lips and remaining the genial kindly
spirit his friends had known, physically incapacitated, but mentally as bright and active as ever.23
A vertical fracture of the anteromedial portion of the
fibula (Wagstaffe tubercle)24 at the site of the anterior tibiofibular ligament is called a Le Fort-Wagstaffe fracture.25
Tillaux-Chaput Fracture
Paul Jules Tillaux (Fig. 8) was born in the region of Calvados,
France, on December 8, 1834. He became a surgeon in 1863 and a
professor of surgery in Paris in 1890. From 1868 to 1890, he was
director of the Amphithe a tre dAnatomie des Ho pitaux de Paris.

Fig. 7

Fig. 8

Fig. 7 William Warwick Wagstaffe. (Reproduced with permission from the


OE club, Epsom College, Epsom, United Kingdom [http://www.
educationtrust-oeclub.org/].) Fig. 8 Paul Jules Tillaux. (Reproduced from:
Wikipedia, The Free Encyclopedia, http://en.wikipedia.org/w/index.
php?title=Paul_Jules_Tillaux&oldid=552638531. [Public domain] Accessed 2013 Sept 28.)

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Fig. 9

A N K L E F R AC T U R E E P O N Y M S

Fig. 10

Fig. 9 Henri Victor Alexander Chaput. (Reproduced with permission from Le


Biblioth`eque de lAcademie Nationale de Medecine [Paris].) Fig. 10 Niels
Lauge-Hansen. (Reproduced with permission from Matthijs P. Somford.)

During experiments on cadavers in 1892, Tillaux discovered


that stress to the anterior inferior tibiofibular ligament could lead to
a certain type of avulsion-type fracture of the tibia. This is recognized as a Salter-Harris type-III fracture that occurs in a specific
period during adolescence when there is a differential rate of closure
of the distal tibial physis, resulting in a closure of its medial portion
before the lateral portion closes. Tillaux died in October 1904. He
was buried at Pe` re-Lachaise Cemetery in Paris26-28.
Henri Victor Alexander Chaput (Fig. 9) was born in
Tonnerre, France, in 1857. He began studying medicine in Paris
in 1876. His third year of study was spent in the Beaujon Hospital, where Tillaux awakened his interest in anatomy. He successfully defended his thesis on old fractures of the patella; in
1885, he received the silver medal of the faculty of medicine for
this thesis. Most of his career he worked in Lariboisie` re. In
1901, Chaput developed surgical gloves that could be sterilized
in an autoclave, but these were meant to protect the skin, not to
be aseptic. These gloves remained in use until the advent of
disposable gloves in 1970. In 1914, Chaput became a consulting
surgeon for the French army. As such, he treated his own son,
who was seriously wounded as a fighter pilot. His son returned
to active duty but was injured again, this time fatally. Shortly
after, overwhelmed by grief, Chaput died in February 191928.
The Salter-Harris type-III fracture of the anterolateral
tibial epiphysis that is commonly seen in adolescents after the
closure of the medial portion of the physis is called a Tillaux
fracture. It is the result of a forced lateral rotation of the foot or
medial rotation of the leg on a fixed foot. This mechanism
results in an avulsion injury through the strong anterior tibiofibular ligament, which attaches to the lateral epiphysis. This
injury was described by Tillaux in 1892 and, later on, Chaput
described a similar injury of the posterolateral aspect of the
tibia, which is called a Tillaux-Chaput fracture.

expeditions to Iceland and the Faroe Islands. In 1942, he published his thesis Ankelbrud (ankle fracture) while working at
the Bispebjerg Hospital in Copenhagen. Beginning in 1943, he
worked as head of the radiology department of the Central
Hospital in Randers. In 1950, he became a member of the main
board of the National Association for Combating Rheumatic
Diseases. From 1959 to 1961, he worked in Seoul, South Korea,
and was made an honorary member of the Korean Medical
Association.
Lauge-Hansen was a man of short stature who hated to
look up to others. As a result, he arranged for the legs of two
chairs used at his desk by visitors to be shortened. By reports,
this desk is still in use in the radiology department of the
Central Hospital in Randers. With use of cadaver specimens
in the 1940s and 1950s, he elucidated the mechanisms involved
in ankle fractures. He wrote his key publications on the subject,
five articles describing five basic mechanisms of ankle injury,
between 1948 and 1956.
This classification system was based on the stability of the
ankle mortise, not only the dislocation and the type of fibular
fracture. As defined by Lauge-Hansen, the five basic mechanisms
of ankle injury are described by two words. The first word refers
to the initial position of the foot at the time of injury; the second
word describes the direction of the injuring force through
the talus. This results in the following possible mechanisms:
supination-adduction, supination-eversion, pronation-eversion,
pronation-abduction, and pronation-dorsiflexion29-33. The trauma
mechanism is meant to guide one to the fracture type and vice
versa, although this is not always easily achieved in daily practice.
He created a very complete but quite complicated classification
system. Because of its complexity, the classification system is not
always used, ironically not even in the Central Hospital in Randers (personal communication).
Danis-Weber Classification
Robert Danis (Fig. 11) was born in Oudenaarde, Belgium, in
1880. He studied in Brussels and graduated in 1904. He first

Fig. 11

Lauge-Hansen Classification
Niels Lauge-Hansen (Fig. 10), the son of a farmer in Jerne, Denmark, was born on May 21, 1899. In 1925, he finished his study of
medicine. From 1926 to 1927, he served in the navy, undertaking

Fig. 12

Fig. 11 Robert Danis. (Reproduced with permission from the AO Foundation, Davos, Switzerland [www.aofoundation.org].) Fig. 12 Bernhard Georg
Weber. (Reproduced with permission from the AO Foundation, Davos,
Switzerland [www.aofoundation.org].)

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became interested in thoracic surgery, followed by anesthesia


and then vascular surgery. In 1913, he started working in a
hospital in a poor area of Brussels. Because there was no capacity for patients to stay over after surgery, this hospital became the first one-day clinic in Belgium where patients could
have surgery for hernias, varices, and breast masses. Follow-up
was done in a patients home.
Danis started early with the operative treatment of fractures. In 1907, the term oste o-synthe` se had been coined for
the first time by Lambotte, who promoted the operative treatment of fractures34. Danis followed this principle and designed
a tension apparatus for fracture compression and fashioned his
own screws with instrumentation. His curiosity reached beyond the borders of medicine. He was fond of astronomy
and designed his own motor vehicle in 1919 because it was
too expensive to buy a car34.
Bernhard Georg Weber (Fig. 12) was born in 1927. He
studied medicine in Basel, Switzerland. In 1959, he began work
under Maurice E. Muller in St. Gallen. Webers ideas enriched
those of Muller and they helped develop the AO Foundation,
which was in its infancy at the time. Weber succeeded Muller in
1967. He had more than 180 publications, which is remarkable for
a man who found writing articles an act of self-gratification.35 He
was most interested in describing his experiences, ranging from
the description of pseudarthrosis to the classification of malleolar
fractures in well-documented books. After his retirement in 1986,
he continued to work full-time in private hospital practice. He
died in 2002.
The Danis-Weber classification is a method of describing
ankle fractures with three categories that focus solely on the
fibula. Type A is a fracture of the lateral malleolus distal to the
distal tibiofibular syndesmosis, type B is a fracture of the fibula
at the level of the syndesmosis, and type C is a fracture proximal
to the syndesmosis. This system was first described by Danis in
1949 and modified and popularized by Weber in 19723,4. It is a
simple and easy-to-memorize classification that is frequently
used.
Discussion
Opponents of eponyms point to the lack of accuracy, intentional misuse, (accidental) erroneous use, and unintentional or
unethical attributions1. Proponents advocate for eponyms to be

retained because they are often practical and provide insight


into medical history and tradition2. Our personal position in
this discussion is with the proponents, but only when eponyms
are used correctly.
In our opinion, the importance of this report is twofold.
First, daily clinical work and communication between colleagues is substantially improved when there is no confusion
about nomenclature or the description of encountered pathology. With its description of various ankle fractures, this article
helps to facilitate the accuracy and appropriate use of eponyms.
Secondly, awareness of the eponyms helps to preserve orthopaedic traditions and history and also commemorates important individuals. Inaccurate or inappropriate use of eponyms
can be prevented with appropriate knowledge.
The information provided on the various fracture descriptions in this article was retrieved, whenever possible, from
the original publication written by the individual whose name
is attached to the term. These publications were studied meticulously while preparing this manuscript. In some cases, the
information in the primary source was not clearly presented.
For example, over the last century, radiographic imaging has
developed from unclear images to high-definition imaging
techniques, leading to a new interpretation of certain pathologies (e.g., calcaneal apophysitis initially was mistaken for a
calcaneal fracture)5. The original manuscripts were matched
with our current knowledge of fracture pathophysiology, terminology, and nomenclature in order to provide the best available evidence-based description of these ankle fractures. n
NOTE: The authors thank Ole Schifter Rasmussen for providing invaluable information on Niels
Lauge-Hansen, Liesbeth Schroth for revision of the language used in our manuscript, and Rebecca
Nieuwe Weme for help with the illustrations.

M.P. Somford, MD
J.I. Wiegerinck, MD
D. Hoornenborg, MD
M.P.J. van den Bekerom, MD
Department of Orthopaedic Surgery,
Academic Medical Centre,
Meibergdreef 15, P.O. Box 22660,
1105 AZ, Amsterdam, The Netherlands.
E-mail address for M.P. Somford: mp_somford@hotmail.com

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1;335(7617):424.
2. Whitworth JA. Should eponyms be abandoned? No. BMJ. 2007 Sep
1;335(7617):425.
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French.
4. Weber BG. Die Verletzungen des oberen Sprunggelenkes, 2nd ed. Bern: Huber;
1972.
5. Sever JW. Apophysitis of the os calcis. NYMJ. 1912;95:1025-9.
6. Dobson J. Percivall Pott. Ann R Coll Surg Engl. 1972 Jan;50(1):54-65.
7. Pott P. Some few general remarks on fractures and dislocations. London: Howes.
Clarke. Collins; 1769.
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