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We review the anatomy and physiology of the ankle joint with attention to the structures most likely to be injured. We discuss the epidemiology of ankle injuries and their physical and radiographic evaluation, including the Ottawa Ankle Rules. Treatment, consultation, and pitfalls are followed by more specific discussions of tendonitis, Achilles tendon injury, tendonous subluxations, tarsal tunnel syndrome, sonovial impingement, and injury to the os trigonum. The references provide a guide for further reading.

A case is reported of a 27-year-old man who presented to an inner city trauma center after he had experienced several seizure-like episodes. He was diagnosed with Lyme carditis and required 6 weeks of treatment with intravenous ceftriaxone for complete resolution of his symptoms. The case is discussed along with a review of the literature.

1.1. Mean levels of right ventricular pressure, flow, and work, but particularly mean levels of right ventricular work, are considerably higher in congenital heart disease than in mitral stenosis. 2.2. In congenital heart disease only abnormal electrocardiograms appeared above a mean right ventricular systolic ejection pressure of 30 mm. Hg. In mitral stenosis normal or borderline electrocardiograms appeared frequently up to a mean pressure level of 60 mm. Hg. 3.3. In congenital heart disease almost all electrocardiograms were abnormal above a right ventricular work load of 1 kg. M./min./sq.M. In mitral stenosis, normal electrocardiograms often occurred at work levels above 1 kg. M./min./sq. M. 4.4. In both mitral stenosis and congenital heart disease, the pattern of partial right bundle branch block appeared at almost all levels of right ventricular pressure and work, and thus this pattern appeared to be almost as significant as the classic pattern of right ventricular hypertrophy in the detection of right ventricular hypertension and presumptive right ventricular hypertrophy. 5.5. Gross electrocardiographic differences between congenital heart disease and mitral stenosis were present in all precordial leads; this was most marked in V 3R and V 1 , where the R wave in congenital heart disease was three to four times as tall as the comparable R wave in mitral stenosis. 6.6. In congenital heart disease, the electrocardiogram is remarkably accurate (91 per cent of cases) in the detection of right ventricular hypertrophy. In this disease no definite correlation was present between abnormalities of individual waves such as the height of R or RS ratio over the right precordium and levels of pressure or work. 7.7. The electrocardiogram in mitral stenosis is less diagnostic (51 per cent of cases) in the detection of right ventricular hypertrophy. But when the electrocardiogram is abnormal, a definite correlation is present between the height of R and RS ratios over the right precordium and levels of right ventricular pressure and work. 8.8. These differences in the total electrocardiographic picture suggest fundamental differences in the genesis of right ventricular hypertrophy in the two diseases.

The selection of patients for mitral commissurotomy must be made after considering all manifestations of the rheumatic state. A conservative approach is urged and no patients should be operated upon without evidences of increasing pulmonary hypertension and right heart strain. The preparation of the patient, the management of the arrhythmias during surgery and the postoperative care are the full responsibilities of the physician. A team composed of physiologists, cardiologists and surgeons must work together.

CONCLUSION The large majority of carefully selected cases of mitral stenosis with functional impairment submitted to commissurotomy benefit from the procedure and in many cases this benefit persists for at least one to three years. A greater degree of benefit can be anticipated in otherwise satisfactory cases when the right ventricular pressure is markedly elevated. Such elevation can usually be predicted when evidence of right ventricular strain is present on the electrocardiogram. In addition to evidence of improvement in respect to functional capacity, hemoptysis, and paroxysmal dyspnea, a large proportion of cases had objectively demonstrable improvement. This is evident in reduction of right ventricular pressure and decrease of right ventricular force on the electrocardiogram. Decrease in heart size by x-ray is an exceptional finding. Mitral commissurotomy with auricular appendectomy is an effective method for controlling peripheral emboli in patients with mitral stenosis. The presence of a calcified valve may not necessarily prevent lasting or significant benefit from the procedure.

The electrocardiographic diagnosis of myocardial infarction of the posterior wall is often missed because it is largely dependent on lead and because this electrode position often does not subtend the diseased myocardium. To remedy this defect, a new method is described—unipolar left back leads. The validity of this method in registering potential from the posterior left ventricular wall is discussed as well as its importance in the diagnosis of myocardial infarction of the posterior wall. Left back leads can illuminate the significance of questionable Q waves.

SUMMARY 1) The resting cardiac output of patients with mitral stenosis is normal, and does not decrease until the onset of heart failure. 2) Pressure levels are more critical than flow levels in estimating the function of the right heart. 3) The most adequate picture of the right ventricular function is obtained from an analysis of pulmonary resistance and of the work of the right ventricle. 4) Patients who are most likely to benefit from mitral commissurotomy are those with high pulmonary artery pressures. 5) The degree of fall of the pulmonary artery pressure following commissurotomy is roughly parallel to the degree of clinical improvement in the few cases studied. 6) Patients with very low pulmonary artery pressures are not benefited by mitral commissurotomy and such low initial pressures may be present in patients with low grade rheumatic myocarditis. 7) Comparison of pre- and postoperative catheterization findings is the only critical method of evaluating results of mitral commissurotomy and should be further pursued. We wish to acknowledge the technical assistance of Mrs. Helen Obernolte, Dr. Andrew Farr, Miss Mary Mayo and Mr. Lucius Collier.