but all voluntary attempts to examine the ankle give great pain, while passive movement of the joint is free. <Callout type="important" title="Important">If a patient under 20 years old has a tender swelling over the tubercle of the tibia and walks with a limp, it may indicate a fracture.</Callout> (6) If in a patient under 20 years of age, with or without the history of a strain or overuse, there is a tender swelling over the tubercle of the tibia and the patient walks with a lump, and the X-ray shows projection forwards and some irregularity of the lingual process of the epiphysis, the condition is <Callout type="risk" title="Risk">Under this head is included a large group of injuries.</Callout> The examination should be meticulous and should aim at determining the position of the various bones, the angle of each toe, and the tendons which are very liable to injury. <Callout type="tip" title="Tip">Check for any increase in the width of the ankle between the two malleoli; this is due to fracture or rupture of the interosseous ligament.</Callout> (d) Measure the distance from either malleolus to the point of the heel, from the outer malleolus to the base of the fifth metatarsal bone, from the inner malleolus to the tubercle of the scaphoid, and from each malleolus to the sole of the foot. (e) Feel the os calcis, the head of the astragalus (talus) in front of the tibia with the scaphoid bone in front of it and concealing its rounded articular end, the cuboid on the outer side, the cuneiform bones in front of the scaphoid, and the bases of the metatarsal bones. 2. Having determined the relative positions of the bones, test each bone for mobility and crepitus. (a) Grasp the ankle and try to move it antero-posteriorly and laterally upon the leg, then seize each malleolus and try to move it. (b) Feel the outline of the os calcis, and notice whether any part of it can be moved, and if the attempt to do so causes crepitus. <Callout type="warning" title="Warning">Notice the range of movement in these joints; a restricted range may indicate injury.</Callout> (c) Move the ankle and transverse tarsal joints, and notice any crepitus, also notice the range of movement in these joints. {d) Test the rigidity of the metatarsus, and of the phalanges, and notice crepitus. <Callout type="important" title="Important">By this examination the following injuries can be recognized:</Callout> 1. If the whole foot is displaced outwards so that the inner malleolus is prominent and there is a depression on the outer side of the leg above the malleolus, and the foot is everted, it is Pott's fracture, i.e., a partial dislocation of the ankle outwards with a fracture of the fibula 3 in. or less from the external malleolus. Very often the foot is also displaced backwards, causing the heel to be markedly prominent. 2. If the whole foot is displaced outwards, the width of the malleoli greatly increased, and the distance from the malleoli to the sole shortened it IS Du^mytrens fracture, i.e., a Pott's fracture plus rupture of the inferior interosseous ligament. 3. If the foot is displaced outwards with the outer malleolus sunk in a deep hollow, and the head of the astragalus projects in front of the inner malleolus it IS a subastragaloid dislocation outwards. 4. If the foot is displaced inwards, the inner malleolus being sunk in a hollow, and the rounded head of the astragalus projects in front of the outer malleolus it is a subastragaloid dislocation inwards. The whole foot may be displaced inwards in some fractures of the lower end of the tibia and fibula 5. If the prominence of the heel is increased and the distance between the malleoli and scaphoid and fifth metatarsal bone lessened, the foot is displaced backwards: this may be due to Pott's fracture, to a dislocation of the ankle, or to a subastragaloid dislocation of the foot. To determine the latter point, feel for the astragalus; if this is under the arch of the tibia so that its convex head is prominent on the top of the scaphoid, and its large saddle surface cannot be felt, the displacement is subastragaloid- while there is no bony prominence in front of the tibia. It is a dislocation backwards at the ankle-joint • the saddle-shaped surface of the astragalus will not be indistinctly felt between the back of the tibia and the tendo Achillis (tendo calcaneus) 214 SURGICAL DIAGNOSIS [chap. 6. If the prominence of the heel is lessened and the distance between the malleoli and scaphoid and fifth metatarsal bones is increased, there is a dislocation forwards. If the saddle-shaped surface of the astragalus is felt in front of the tibia, it is a dislocation forwards of the ankle; while if this cannot be felt, but the rounded head of the astragalus projects a short distance in front of the tibia, it is a subastragaloid dislocation of the foot. 7. The foot being in line with the leg, the heel may be displaced outwards from dislocation of the os calcis — a very rare accident. 8. If there is no gross deformity of the foot but the heel is painful and swollen, and the patient is unable to bear weight on the foot, and no crepitus or pain is elicited on passive movement of the ankle, there is probably a fracture of the os calcis. 9. If the malleoli are approximated to the sole, but not widened, and the foot is not displaced forwards or backwards, there must be a dislocation of the astragalus (talus); the bone may be found in front of or behind the tibia — in front its outline is easily recognized. But if the malleoli are greatly widened and the heel raised, and the foot is, as it were, buried between the malleoli, there is dislocation of the foot upwards between the bones of the leg. 10. If the front half of the foot is displaced and the front of the os calcis projects on the outer side and the scaphoid projects much beyond the astragalus and malleolus on the inner side, it is because there is dislocation inwards at the mid-tarsal joint. If the lateral projection is farther forwards, it is due to dislocation of the metatarsus; the displacement of the metatarsus may be to either side, or on to the dorsum of the tarsus or into the sole. XVI] INJURIES OF FOOT 215 11. A single tarsal bone may be felt dislocated on to the dorsum of the foot; the position and outline of the projection determine the diagnosis 12. In the toes a dislocated phalanx may be recognized. 13 When the foot is grasped at the ankle and moved laterally or antero-posteriorly, there may be yielding of the tibia and fibula and crepitus, showing fracture of the bones close above the ankle; in some cases the foot slides up and back owing to there being an oblique fracture of the back of the tibia. In young people under 18, if the crepitus is soft it would indicate separation of the lower epiphyses of the tibia and fibula. <Callout type="important" title="Important">Either malleolus may be found movable owing to fracture or there may be a separation of the epiphysis of the fibula.</Callout> 15. The tuber calcis may be movable either from fracture or diastasis. <Callout type="warning" title="Warning">If there is deep crepitus and any attempt to stand causes severe pain, the symptoms are probably due to fracture of the astragalus (talus).</Callout> 17. Mobility in the metatarsus or in a phalanx with crepitus will indicate fracture of these bones 18. If there is no displacement of any bone nor crepitus, but the patient complains of pain in front of either of the malleoli, and an elongated sinus felt there, it is a displaced tendon; the tibialis posticus may slip over the internal malleolus, and the peroneus longus over the outer malleolus. Peroneus
Key Takeaways
- Use a thorough examination to identify foot fractures and dislocations.
- Pay attention to the position of bones, tendons, and sinuses during diagnosis.
- Recognize specific signs like crepitus and displacement.
Practical Tips
- Always perform a detailed physical examination when suspecting a foot injury.
- Be aware that young patients may have more flexible bones, affecting their symptoms.
- Use palpation to check for tenderness and mobility in the affected area.
Warnings & Risks
- Do not attempt to move or manipulate an injured foot without proper training, as this can worsen the injury.
- Be cautious of deep crepitus and severe pain when standing, which may indicate a serious fracture.
- Avoid making assumptions about the severity of injuries based on external appearance alone.
Modern Application
While the techniques described in this chapter are rooted in historical practices, they provide foundational knowledge for diagnosing foot injuries. Modern medical imaging and equipment have improved diagnostic accuracy, but understanding these basic principles remains crucial for emergency responders and first aid providers.
Frequently Asked Questions
Q: How can I determine if a patient has Pott's fracture?
If the whole foot is displaced outwards with the inner malleolus prominent and a depression on the outer side of the leg above the malleolus, it may indicate a Pott's fracture. This condition involves a partial dislocation of the ankle outward with a fracture of the fibula 3 inches or less from the external malleolus.
Q: What should I do if I suspect a patient has a displaced tendon?
If there is no displacement of any bone nor crepitus, but the patient complains of pain in front of either of the malleoli and an elongated sinus felt there, it could be a displaced tendon. The tibialis posticus may slip over the internal malleolus, or the peroneus longus over the outer malleolus.
Q: How can I check for crepitus in the foot during examination?
During an examination, if there is deep crepitus and any attempt to stand causes severe pain, it may indicate a fracture of the astragalus (talus). Crepitus can be felt by moving the ankle and transverse tarsal joints and noticing any grinding or crackling sounds.