160 



ABNORMAL CONDITION OF THE ANKLE-JOINT. 



range of the tarsus, a situation which the tibia 

 could not well occupy, without a previous 

 lesion of the tendons of the tibialis anticus, 

 and stretching of the other extensors : from 

 such a relative position of the bones of the leg 

 and foot would result a shortening of the dorsum 

 of the foot and an elongation of the heel to an 

 extent which, we believe, has never been no- 

 ticed. 



Partial luxation of the tibia forwards, with 

 simple fracture of one or both of the malleoli. 

 The complete luxation forwards of the tibia 

 from the astragalus, which we have described 

 in the preceding section, all writers look upon 

 as the more common form of dislocation for- 

 wards ; while the partial luxation in this di- 

 rection is considered a rare accident. My 

 opinion upon this subject is quite different ; 

 for some experience in these accidents leads 

 me to say, that a complete luxation of the tibia 

 forwards from the articular pulley of the astra- 

 galus is rare, but that a partial luxation in this 

 direction accompanied with a simple fracture 

 of one or both of the malleoli, is an accident 

 by no means uncommon. 



The signs of this partial luxation of the tibia 

 forwards are nearly the same as those we have 

 stated to belong to the complete luxation in 

 this direction ; they are, however, as might be 

 expected, more faintly marked, and, conse- 

 quently, may more easily be neglected ; but, 

 after all, these signs are so evident, that it is 

 wonderful how with common attention they 

 can be overlooked. It may not be amiss to 

 subjoin the following case as illustrative of the 

 common partial luxation forwards : 



A man, aged twenty-two years, was ad- 

 mitted into Jervis - Street Hospital, at three 

 o'clock, A.M. of the 26th of December, 1833. 

 He stated that he and a friend had been 

 drinking together in a public house, that in 

 the middle of the night they quarrelled, that 

 he was knocked down, and was unable to rise, 

 in consequence of his having received a severe 

 injury of his left ankle : his friend then pro- 

 cured some assistance and carried him to the 

 hospital ; at my visit, I found him in bed, 

 complaining of much pain, his leg extended 

 and resting on its outer side ; the heel was re- 

 tracted, and between it and the calf of the leg, 

 instead of the ordinary line which marks the 

 course of the tendo Achillis, there was a 

 conspicuous semicircular curve, (Jig. 57, a, l>) ; 

 in a word, the heel was lengthened, and the 

 dorsum of the foot seemed much shortened ; 

 in the situation of the ankle-joint in front, 

 there was a remarkably hard, prominent, trans- 

 forme internum, quitting all the articulatory sur- 

 face of the astragalus, excepting a small portion on 

 its fore part, against which the tibia is applied." 

 Now, a single glance at the skeleton of a foot will 

 shew us, that a portion, however small, of the ar- 

 ticulatory surface of the astragalus, together with, 

 secondly, the upper part of the neck of this bone ; 

 thirdly, the os naviculare ; and, fourthly, the os 

 cuneit'orme internum, nearly form a space equiva- 

 lent to a third of the length of the whole foot, 

 an extent of surface, which, manifestly, the arti- 

 culating portion of the dislocated tibia could not 

 occupy. 



verse ridge made by the advance of the lower 

 extremity of the tibia and extensor muscles of 

 the toes, while beneath this there was a marked 

 depression, where the skin and annular liga- 

 ment seemed, as it were, pinched in, drawn 

 under the lower edge of the articular part of 

 the tibia ; the foot was pointed downwards, 

 no movement of flexion or extension could be 

 communicated to the ankle-joint, but it ad- 

 milted of some little motion in a horizontal, 

 and also in a lateral, direction, when the leg 

 was firmly grasped with one hand and the foot 

 moved with the other. 



It was remarkable that, although the man 

 had no power whatever over the motions of 

 the joint, he could, while he lay in bed, move 

 his whole limb about with much freedom, and 

 (as there was probably a locking of the bones 

 with each other) these voluntary movements 

 were not accompanied by any increase of 

 pain. 



The fibula could be felt to be fractured 

 about an inch and a half above the lowest 

 point of the outer malleolus, " the foot, the 

 outer malleolus, and short portion of the 

 broken fibula, formed one system of parts," 

 and were carried for the length of an inch or 

 more horizontally backwards, while there was 

 a projection forwards, of the lower articular 

 part of the tibia, and the internal malleolus 

 itself was advanced in the same proportion : 

 it is to be observed, that there was no crepitus, 

 because it was the deltoid ligament only which 

 was torn ; the tibia was not broken, and 

 the ends of the fractured fibula were evidently 

 far separated from each other. When the 

 luxation was reduced, which was effected with- 

 out much difficulty, crepitus could be felt, 

 proving the restoration to its place of the 

 lower fragment of the fibula. 



This is a species of fracture and luxation, 

 which can, by proper management, be readily 

 redressed, and no deformity remains, if time 

 be not lost after the accident has occur- 

 red ; but if the fibula become solidly united 

 in its new situation, the motions of the ankle- 

 joint are for ever lost, and the patient is doomed 

 to lameness for life. 



In the month of September 1833, a woman, 

 aged fifty-three years, was admitted into Jervis- 

 street Hospital, whose left ankle-joint presented 

 all the characters above assigned to the partial 

 dislocation forwards of the tibia, combined with 

 a simple fracture of the fibula ; she stated that 

 she had, two months previously, broken her 

 leg close to the ankle joint, and had been at- 

 tended at her own house, from a dispensary, by 

 a pupil, who applied pads and lateral splints, 

 but when after a time all the splints were re- 

 moved, she found that her limb was deformed, 

 her ankle stiff, her foot rigidly extended, and 

 pointed downwards, so as to be nearly useless 

 to her; as two months had elapsed since the 

 accident, before she applied, no promise of 

 relief could be held out to her. She there- 

 fore left the hospital, but not before I was 

 enabled, through the kindness of Mr. Sutton, 

 to obtain a cast of the leg and foot, from 

 which figures 57 and 58 are copied. As I 



