DOI: 10.7925/drs1.ucdlib_280539
title: Dislocations of the tibia and fibula

description: Watercolour medical illustration depicting dislocations of the tibia and fibula in a man. It has the alternative reference number 1758 and P18 on the front. The Richmond Hospital Museum reference is C.b.63. The entry for this in P263/1 pg. 23 reads 'Sketch showing the mode of production of the injury at the ankle. Wm Jury aet 30. Mr Smith'. The feint handwritten note in the bottom left corner reads 'Sketch showing mode of production of injury'. This illustration relates to P263/538, portfolio 9.1.
description: Scope and content: The typescript note on the back reads 'Dislocation of the Tibia and Fibula backwards at the Ankle – Professor R.W. Smith exhibited a cast and a series of drawings illustrative of this extremely rare form of luxation, and gave the following history of the case: A man, aged 29, a sailor, was admitted into the Richmond Hospital upon the 13th of February 1852, for an injury of the right-ankle joint, sustained seven months previously. He stated that he was in the hold of a vessel, arranging the tackle upon a large cask of paint weighing 13cwt., which it was necessary to raise to the deck; one end of the cask was resting upon a loose mass of flint, employed as ballast, and raised above the other, upon which both hooks of the chain were fixed, the object being to shove the cask round, in order to bring it under the opening of the hatchway. He was standing at this end of the cask, giving it the proper direction with his hands according as it was raised; with his left leg resting upon a small box, and his right foot placed diagonally across two provision casks, which lay side by side in contact with each other; the foot was flexed upon the leg, the leg strongly bent upon the thigh, and the thigh flexed upon the pelvis; the limb was in such a position that the knee was advanced several inches beyond the ankle-joint, and placed directly beneath the extremity of the cask, which was now raised about a foot above it. According as the cask approached the vertical direction, the hooks, of course, had a less secure hold; and when it was about 18 inches above his knee they slipped off entirely, and this enormous weight of 13 cwt. Fell upon the lower end of his femur, immediately above his patella, driving the leg downwards and backwards between the two small casks, until the foot was stopped by the floor of the hold of the vessel, the front of the foot coming into contact with a large piece of flint, by which its flexure upon the leg was augmented. He remained in this position for about a minute, while the hooks were being readjusted and the cask again raised; the limb was then extricated, and he was brought up and laid on the deck. He was visited in less than half-an-hour by the surgeon and assistant-surgeon of one of Her Majesty's vessels of war, which was at the time lying in the same harbour. These gentlemen, after a brief consultation, had recourse to a strong and protracted extension of the limb; the patient was then taken ashore, and in the evening he was again visited by the assistant-surgeon, who, grasping the hell with one hand and the dorsum of the foot with the other, again applied as powerful extensions as he was capable of, and then informed the man that every thing was now in place. The patient, however, asserts positively, that upon neither occasion was the appearance of the limb in the slightest degree altered, and that the deformity which the foot now presents has existed unchanged from the moment of the occurrence of the injury. A splint, similar to that employed by Dupuytren for fracture of the fibula, was now placed upon the inner side of the leg, and the foot secured to it in the position of adduction. Upon the following day, however, the swelling was so great, that it was necessary to remove the splint; nor was it applied again for three weeks; it was then put on and worn for two months. Upon the 1st October, about three months after the occurrence of the accident, the vessel to which the patient belonged, sailed and arrived at the port of Dublin a few days before the man presented himself at the Richmond Hospital. He was at once received into the hospital, and an accurate examination of the limb having been made, the following results were obtained:-The muscles of the calf of the leg were wasted, and the limb was from half to three-quarters of an inch shorter than its fellow; the natural prominence of the heel had altogether disappeared, and the curve of the tendo Achillis was effaced, the tendon passing down to its attachment in a straight and vertical direction. The dorsum of the foot in front of the tibia was exactly one inch longer than upon the sound side; the external malleolus was placed seven inches behind the extremity of the fifth toe, and one in front of the tendo Achillis, while upon the opposite foot the former measurement was six inches, and the latter two; it was likewise rather more than half an inch nearer than natural to the outer margin of the sole of the foot. The lower extremity of the tibia could be felt, and was distinctly visible through the integuments, immediately in front of the tendo Achillis, forming a striking and remarkable prominence at the posterior and inner part of the region of the ankle; it was difficult to ascertain accurately the point of the internal malleolus, as this portion of the bone appeared altered from its natural form; its most inferior part was, however, nearer the sole of the foot than the inner ankle was upon the sound side. The anterior part of the superior surface of the astragalus could be felt, but it was impossible to distinguish the entire of its articular surface; it seemed to be in a great measure concealed by the extensor tendons. The antero-posterior arch of the foot was increased, so much so that the planter region was fully an inch less in extent than upon the opposite side. The foot, which had a tendency to rest principally upon its outer margin, was placed at a right angle with the leg, and could be neither flexed nor extended. It was colder than natural, and the patient (who was unable to throw the weight of his body upon it) complained that it was frequently the seat of numbness and distressing tingling sensations. The course of the posterior tibial artery at the ankle could not be discovered. Upon the outer side of the leg, immediately in front of the lower third of the fibula, a very prominent tendon was seen passing down towards the fifth metatarsal bone; it may, probably, have been that of the peroneus brevis, displaced from the groove. That the preceding case is to be looked upon as affording an example of luxation of the tibia and fibula backwards at the ankle just, I imagine, be apparent to all who consider attentively the symptoms which the limb presented, and reflect carefully upon the mode in which the injury was inflicted. The following are the signs which constitute the proofs of the luxation of the tibia:- The shortening of the leg, the double approximation of the lower end of the tibia, to the sole of the foot upon the one part, and to the anterior surface of the tendo Achillis upon the other; the effacing of the curve of the tendon and of the prominence of the heel; the elongation of the anterior part of the dorsum of the foot; the exposure to the touch of the front of the upper surface of the astragalus, and the evidence of pressure upon the posterior tibial artery and nerve, derived from the coldness and numbness of the foot. I shall presently endeavour to show that the preceding symptoms cannot be explained upon the hypothesis of fracture of the tibia close to the joint, with displacement of the upper fragment backwards. That the injury which the fibula had sustained was a dislocation and not a fracture is apparent from the approximation of the external malleolus to the posterior extremity of the os calcis; for no simple fracture of the fibula could alter the relative normal bearings of its malleolar process to the astragalus and os calcis. As regards the mode in which the accident happened, no conjecture of circumstance could possibly be imagined more favourable to the production of a dislocation of the leg backwards at the ankle, that that under which the injury occurred in this remarkable case. The thigh was flexed at a right angle with the body, the leg bent upon the thigh, and the foot flexed upon the leg; the foot was in such a position that its anterior part was above the level of the heel, so that the articular pulley of the astragalus was directed from before backwards and downwards; the knee was not only considerably bent, but also advanced far before the ankle-joint. It is obvious that, under these circumstances, the tendency of a force applied to the upper part of the knee would be to drive the tibia downwards, and to cause it to glide from before backwards off the articulating surface of the astragalus. The first effect of the falling of the hogshead upon the knee was to drive the leg down between the two small provision casks upon which the foot had been resting; the luxation, no doubt, did not occur until the foot came in contact with the floor of the hold of the vessel; the limb was then placed between two forces acting in opposite directions-one, the resistance of the floor tending to drive the foot upwards, the effect of the other (the superincumbent weight) being to force the tibia downwards and backwards. Had the weight fallen from any considerable height, in all probability a compound comminuted fracture would have resulted; but the distance being not more than a foot and a half, the opposite extremity of the hogshead being supported, and the leg yielding to the pressure until the foot came in contact with the floor, the tendency of the force would rather be to push the bones from their place. Some idea of the force of the pressure to which the parts were subjected may be formed from the fact , that (there being no wound in the integuments) the blood oozed out in drops from the pores of the skin stretched over the end of the dislocated tibia. Although the majority of systematic writers upon surgery have described the symptoms of luxation of the tibia backwards at the ankle, Nelaton alone appears to have both seen the injury and to have had an opportunity of investigating, post mortem, its anatomical characters; but it is forever to be regretted that the details of the symptoms, and of the dissection of the limb, are so deficient as to deprive this case of nearly all the importance that would otherwise attach to it. The whole subject of the dislocation in question is thus disposed of:- "La luxation du pied en avant se produit par un mecanisme analogue, le pied etant fortement fleche; nous avons vu une luxation produite d'apres ce mecanismesur une jeune femme qui fut jetee par une fenetre du quatrieme etage, et tomba sur les pieds de manière a toucher le sol pas les talons. Dans ces cas, le bordanterieure de la mortaise tibiale avait ete separe, et les asperites de l'os resultant de la fracture ayant glisse d'avant en arriere sur la poulie de l'astragale, avaient imptime sur son cartilage des sillons que l'on peut facilement reconnaitre a l'autopsie, et qui ne pouraient laisser aucun doute sur la succession des mouvements qui avaient precede la luxation".[Elemens de Pathologie Chirurgicale, par A. Nelaton, tom.ii, p.477].In the Cyclopaedia of Anatomy and Physiology [Page 161], Mr Adams has recorded the particulars of a case of injury of the ankle (as far as they could be ascertained) observed by the late Mr Colles, who had a cast taken of the limb. "In this case", says Mr Adams "the tibia seemed thrown partially backwards from the articular pulley of the astragalus; 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 occupied the lower and back 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 Steeven'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." It is difficult to pronounce with certainty upon the exact nature of the injury in this case, but there are certainly grounds for believing that it was not one of simple luxation of the tibia backwards, but rather of fracture of the lower end of that bone close to the ankle-joint, with displacement of the upper fragment backwards. This view of the case, put forward by Mr Douglas, of Glasgow, has been adopted by Sir Astley Cooper, as appears from the following quotation from his work on Dislocations and Fractures [edition by Bransby Cooper, p.259]:"No instance has been recorded by any individual of a dislocation of the tibia backwards from the astragalus. In the Cyclopaedia of Anatomy, a case by Mr Colles, of Dublin, is noticed, which was supposed to be one of dislocation backwards; but I suspect, says Mr Douglass, it must have been one of fracture close to the ankle-joint, such as I am going to describe." The following is an abstract of the case alluded to:- A man, aged 41, was admitted into the Glasgow Infirmary in July, 1834. There years before he had fallen from a height of sixty feet, and was struck on the front of the leg, close to the ankle, by a plank which fell on him. A fracture above the articulation took place, and a false joint formed. On examination, the lower part of the tibia, with the internal malleolus, was felt attached to the astragalus, while the shaft of the tibia was thrown backwards. The leg was three-quarters of an inch shorter than the right, and the foot seemed lengthened in front and shortened behind. When he walked, the lower end of the shaft pressed against the tendo Achillis, making it project backward. The fibula was seen projecting on the outer side in a similar manner. The man insisted upon having the leg amputated. Upon dissection, the tibia and fibula were found to be fractured transversely immediately above the ankle-joint, which remained perfectly uninjured. The shafts of the bones passed backwards and downwards. The end of the tibia did not rest on the os calcis, but pressed backward and downward against the tendo Achillis. In the accounts of luxation of the lower extremity of the tibia backwards, given by those authors who have described the accident without having ever seen it, it is stated that the displacement takes place while the foot is extended upon the leg. Baron Boyer, for instance, thus expresses himself when describing the dislocations of the foot: "La luxation en devant ne peut avoir lieu que dans une extension force et subite de jambe sur le pied, lorsque celui-ci etant engage et retenu par un obstacle quelconque, on tombe a la ren…" [the next column of text is a repeat of that above, so the next section is missing]… means of distinguishing between this and the partial luxation, in which the concavity of the tendon is merely effaced. As yet, however, there are no data upon which to form a positive opinion respecting the anatomical characters of either form of this rare and remarkable displacement.In his work upon the Principles and Practice of Surgery, lately published [page 337], Mr Pirrie states, that he once had the opportunity of seeing an example of dislocation of the lower end of the tibia backwards in a girl fourteen years of age; the injury occurred two years previous to his seeing it, but the nature of the accident has not been mentioned; no attempt had even been made to reduce the displacement. The foot in front of the malleoli was greatly lengthened, the heel and back of the leg were in a line with one another; the malleoli were unbroken and driven backwards, preserving their natural bearings to each other. Whenever the girl threw the weight of her body upon the foot, its anterior extremity bent upwards, so as to render walking impossible. The tibia seemed to rest upon the os calcis behind the astragalus.Is it possible that this case could have been one of separation of the lower epiphysis of the tibia, with displacement of the shaft of the bone backwards? The early age of the girl, and the circumstance of the two malleoli preserving their natural relations to one another, favour this idea; but the statement (vague though it certainly is), that these processes were driven backwards, is opposed to it. It is much to be regretted that measurements were not made of both limbs, so as to ascertain exactly in what respects the malleoli upon the injured side had lost their normal bearings to the different parts of the skeleton of the foot. In the brief description of the case noticed by Nelaton, no mention is made of the condition of the fibula, but in the other instances recorded as luxations of the tibia backwards, it is remarkable that the fibula, unbroken, was also displaced, the reverse of what usually happens in the dislocation of the tibia forwards. I have, however, twice seen the latter injury without fracture of the fibula.It should not be difficult to distinguish the accident which I have been considering from other injuries occurring in the vicinity of the ankle-joint. The separation of the lower epiphysis of the tibia with displacement of the shaft of the bone backwards is, probably, the accident which would bear the strongest resemblance to it; but in the latter there would be no disturbance of the natural relation of the malleoli either to one another or to the bones of the foot, whereas in the former these processes would, of course, be approximated to the posterior extremity of the os calcis. The circumstances of the malleoli preserving their proper relations to the os calcis would, of itself, indicate the true cause of the elongation of the front of the foot, and of the effacing of the prominence of the heel. – February 14, 1852'.
description: Numbering/sequence: Original reference number: 1758.