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 tensor tendons were stretched over the tibia, and were somewhat flattened, and the grooves which transmit the tendons that play behind the inner and outer malleolus were deepened. We now directed our attention to the state of the bones; we found that the tibia was dis placed forwards, that its anterior edge was ad vanced more than one inch beyond its natural situation, and that it much overhung the os naviculare, but such was the direction and state of obliquity of the tibia with respect to the foot, that it could not be said to rest upon that bone; between the os naviculare and the infe rior articular extremity of the tibia ,there inter vened much fat of a yellow hue and fibrous texture, like intervertebral substance the inter nal malleolus itself had not escaped injury, the deltoid ligament had not in this instance as in the former given way ; the internal malleolus itself had been broken, and a small portion of the back part of the edge of the articular cavity of the tibia was detached, and both malleoli were retracted, or carried backwards with the foot; the fibula above the fractured portion was directed down wards and a little forwards, and was somewhat parallel to the tibia, yet more than naturally approximated to it, a circumstance which ac counted for the contracted rounded form the middle of the leg possessed ; the lower frag was anxious, before these pages went to press, again to examine this case, I requested Mr. S. to make inquiry about her; he learned that the woman died dropsical a few days before, and with much difficulty procured for me an opportunity to examine the limb, which on careful dissection presented the following ap pearances :—the whole extremity was somewhat wasted, the skin on the sole of the foot was smooth and fine, spewing that she had been able to walk but little since the accident ; the foot was in a position of almost rigid extension, the toes were directed downwards, the range of motion of flexion and extension did not exceed one inch, in short, all the usual characters assigned to the partial dislocation forwards of the tibia and displacement of the foot back wards were seen ; when the skin was re moved from the fascia of the leg and foot, the intervening cellular membrane was found infiltrated with serum, the skin was adherent to the inner malleolus, the veria saphena and the nerve of the same name were thick ened and firmly connected together, the ex nient of the fibula was directed from below upwards, a little inwards, and very inuch for wards, so as to make with its shaft a remark able angle salient anteriorly ; this bone had been traversed by the fracture obliquely, from above downwards and from before backwards. The external malleolus was placed about one inch and a quarter behind its usual situa tion, and was consequently dislocated at its tibio-fihular articulation, having burst those strong ligaments which connect these bones together, and which are so seldom found to yield.
Luxation of the bones of the leg backwards at the ankle-joint.—A luxation of one or both bones of the leg at the ankle-joint backwards, whether the accident be what has been called complete or incomplete, whether accompanied with a fracture of the fibula, or merely with a rupture of the ligaments, is a displacement which must be considered exceedingly rare. Boyer, in his valuable work, gives no case of it from his own observation ; and in alluding to such an accident, states that no author, to his knowledge, has given a single example of it. Sir A. Cooper evidently has not seen it; for he says, " I have seen the tibia dislocated in three different directions, inwards, forwards, and outwards ; and a fourth species of disloca tion is said sometimes to occur, viz. back wards." Baron Dupuytren states that he has never seen this accident.* Mr. Colles has given me the notes of one case, and it is the only one he can, in his exten sive experience, recollect to have met with, of a partial dislocation of the lower part of the tibia and fibula backwards, and has also shewn me the cast he had taken of the leg. In this
case the tibia seemed thrown partially back wards, from the articular pulley of the astraga lus; the fibula was unbroken, and was also carried backwards with the tibia; the foot, measured from the instep upon its dorsum, was longer than that of the opposite side, the heel was shorter and less pointed, the space in front of the tendo Achillis, near to the os calcis, was partially filled up, and a hard swelling oc cupied the lower and back part of the tibia, which was evidently formed by a quantity of callus, which had cemented together the frag ments of a fracture of the lowest part of the tibia ; the leg was shorter than the opposite limb.
It would have been interesting to have learned the precise manner in which this accident had occurred ; but as to this, or the immediate symptoms which followed the injury, I could get no satisfactory information. The man did not apply to Stevens's Hospital until the bones were united in their new and faulty position. Besides the partial dislocation backwards of the tibia, this bone with the outer malleolus of the fibula was inclined somewhat outwards; and the man walked lame and most awkwardly on the outer edge of the heel and foot, the inner side of which was somewhat curved inwards.
I have had occasion to notice a displace ment of the tibia backwards on the os calcis, in a case where the astragalus sloughed in con sequence of a compound injury to the external malleolus and ankle-joint ; but such a case is different from that now under our considera tion, although the possibility of such an occur rence should not be lost sight of.
2. Morbid anatomy. a. Acute iqflammation of the synovial membrane of the ankle-joint produces changes in the synovial fluid of the articulation both in quantity and quality, and alterations very generally in the appearance and structure of the membrane ; I say very generally, for I have known an exception to the rule, in a case's of acute synovitis of the ankle-joint which caused the death of the patient in fifty hours from its first onset ; during the whole of the time the patient never slept nor ceased to com plain of the agonizing pain of the ankle-joint. At the post-mortem examination, before the skin was removed, the extensors of the toes were observed to be displaced by the fluid which distended the synovial sac of the articulation, and fluctuation was now, as during life, to be felt in two tumours which existed in front of the two malleoli ; the interior of the joint was occupied by a turbid oily synovial fluid ; no false membrane existed, and if there had been increased vascularity during life, no trace of it was discoverable at the time of examination : increased quantity with altered quality of the synovial fluid were the only deviations from the normal condition which could be noticed. Portions of the synovial membrane are, how ever, occasionally found covered with false membrane. Pus has also been found in the joint, sometimes laudable, sometimes foetid, and of a brownish red colour; the membrane has been found thickened, and has afforded evidence of increased vascularity, and even in some points has presented a villous ap pearance. In very young subjects I have known acute inflammation of the ankle-joint in a few days extend itself to the epiphysis, and produce of it from the shaft of the tibia; and in such cases a displacement of the shaft inwards, and of the epiphysis and foot outwards, occurs from the action of the muscles, as in Pott's luxa tion. Acute inflammation commencing in the synovial membrane of the ankle-joint sometimes extends farther than this : there have been cases in the Richmond Hospital, and the specimens have been preserved in the museum, of acute synovitis of the ankle in which the inflammation extended through the vascular junction of the epiphysis and shaft of the tibia, and having occupied the cellular junction of the periosteum with the anterior and inner surface of the tibia, soon ended in the formation of pus and lymph, which detached from the bone its immediate covering, and produced effects which termi nated in the death of the patient. I have seen this detachment of the lower epiphysis of the tibia in an infant six days old, the result of acute synovitis, with purulent deposition in the joint, and in a young man aged twenty, but have not observed it ever to occur in older subjects ; and conclude that it is one of the consequences synovitis of the ankle-joint, which is only to be noticed at an age when the epiphyses are not yet consolidated with the shaft of the tibia.