Glucagon and diabetes

1973 BMJ (Clinical Research Edition)  
Fractures of the os calcis are important ibecause of the severe disalbility they cause. They occur mainly in men whose work requires them to climb heights or who are heavy manual workers. They incapacitate patients frequently at the peak of their earning power and at a time when their financial commitments are greatest. The fractures were classified by R. Watson-Jones into three types.' This classification is useful because it reflects the degree of trauma causing the injury and it indicates
more » ... prognosis. Type A fractures are isolated fractures of the calcaneum, and they may be commnu,ted. They are caused by less severe trauma than the others, and the resultant prognosis is good. Type B fractures have minimal injury to the posterior talo-calcaneal joint, and type C show significant displacement and involvement of this joint. The last two types of fracture are rarely shown in full by the standard radiographs of the bone, and special views of the posterior talo-calcaneal joint are essential. S. Nade and P. R. W. Monahan have reported a series of 203 fractures of the calcaneum in 185 patients seen at the Radcliffe Infirmary, Oxford.2 Almost a quarter were occupied in climbing heights and another quarter were heavy manual workers. Children were rarely affected. Falls from heights were responsible for most of the type C fractures, whereas less severe accidents, such as twisting, falls from kerbs or stairs, or crush injuries, were responsible mainly for type A and B fractures. Type C was the most common fracture and type B was the least common. In this series 28% of the patients had other injuries. These were mainly to the same foot or limb, but five patients had vertebral fractures and 13 had other lesions. Pain, bruising, and swelling of the heel are the presenting features of this fracture, and the heels are tender to touch on examination. In the face of such an dbvious injury further examination of the patient might be thought unnecessary, but this is essential because of the risk of other injuries, especially vertebral fractures. The pain from ithese calcaneal fractures is so severe that it may mask the pain from the other injuries. A full radiographic investigation of all tender areas is essential. The treatment reported by Nade and Monahan in their study was not uniform, and this variation reflects the general opinion among surgeons. While all their patients were treated conservatively, they recommend ithat the place of sur-gery should be reviewed. Most surgeons treat their patients conservatively, but the exact method of treatment varies. Crepe and wool bandages and raising the affected foot with the patient rested in bed comprise the simplest treatment. Admission to hospital is indicated if there are other severe injuries. Analgesics initially are essential and trypsin-chymotrypsin tablets may help to disperse the haematoma. The application of a well-padded plaster below the knee often provides the patient with more comfort. Because the os calcis in type C fractures is broadened when viewed from behind, manipulation under anaesthetic during application of the plaster is sometimes undertaken in an attempt to moul:d the bone into a more normal shape. This enables the patient to wear a normal shoe later when he has recovered. Surgical treatment is essential in all open fractures, but in closed fractures opinions vary about surgery. Operative procedures include raising the superior border of the os calcis with a Steinmann pin inserted through the heel and bone-grafting the os calcis to achieve the same result and finally fusion. Early fusion was advocated by Watson-Jones because he was so disappointed by the long-term resuits of these fractures, but most people wait to see the end product before embarking on this procedure. The fusion undertaken might be a local suibtalar fusion or even a triple fusion involving the subtalar and midtarsal joints. Nade and Monahan's patients who were admitted to hospital stayed for an average duration of 6-7 days and were away from work for 15-6 weeks, the range for the latter being 7-3 weeks for type A and 23 weeks for type C. Symptoms can be expected to improve for two years, but even after this time patients may have complaints. These are pain, local swelling, stiffness, cold feet, and cramps. Patients with type C have the worst symptoms. In Nade and Monahan's study 57% of patients were so affected, and many suffered loss of agility, being unable to stand unaided on tiptoes, walk on uneven ground, and climb ladders; 17% thad been granted a governmental disability pension ranging from 5 to 20%. Of the patients with bilateral fractures, only one from whom the information was available returned to work within six months. Patients suffering these fractures are faced with a long period of pain and disability, loss of pay, loss of function, and perhaps loss of work. A satisfactory treatment has yet to be devised. Diabetes mellitus is characterized by relative or absolute deficiency of insulin. Three of its main biochemical featureshyperglycaemia, increased mobilization of body fat, and increased protein cataboism-appear to 'be primarily caused by lack of the normal restraining influence of insulin on gluconeogenesis, triglyceride hydrolysis, and protein turnover respectively. Insulin's action in regulating fat mobilization and protein turnover appears to be mainly at the level of the peripheral tissues. By favouring protein synthesis and inhibiting proteolysis, insulin controls the flow of glucogenic amino-acids to the liver, where they may be subsequently converted to glucose.' In a similar manner insulin promotes
doi:10.1136/bmj.3.5875.310-a fatcat:vnp33qrwv5d7fgumwjwtwf5wti