Ankle joint

“ If the ankles were to be used but a day or a week, such support might serve; but as no one intends to rely permanently upon such artificial support, and as any pressure checks the circulation and the development of the parts, so a lacing to the ankle, as a lacing about the chest, may feel comfortable and give a sense of support for the time being, but, in either case, will, in the long run, only produce absorption and weakness. The ankle joint should be left entirely without ligature, without any pressure, and by exercise be developed into a self-supporting institution. ”

“ The exciting cause, or that which called her attention to her foot, was the alleged slipping of the tendon of the peroneus longus muscle where it passes under the outer ankle-bone. She had no theory, fancy, or any other sentiment regarding her lameness whatever. She simply dropped her toes when walking, and was obliged to lift that limb very high to advance the foot and prevent stumbling. When, in examining her, I asked her to raise the foot, she was unable to do so. The muscles moving the ankle-joint were powerless. ”

“ There is intense pain and abnormal position in the injured part, besides deformity produced by the swelling. The foot of the injured limb is turned over to one side or the other, [Pg 107] owing to a rolling over of the portion of the limb below the break. With both lower limbs in line with the body, and the patient lying on the back, measurements are made from each hip-bone to the prominence on the inside of either ankle joint. Shortening of the injured leg will be found, varying from one to over two inches, according to the overlapping and displacement of the fragments. ”

“ No. 260. Some changes have been made in the ankle joint, but the notable modifications are a foot with thick sponge-rubber removable sole, K-K, in place of the rubber-covered core; for thigh amputations an adjustable steel knee cord and spring piston, combined in one piece, E, and knee-joint tightener, A.
The removable sole gives us an opportunity of strengthening the upper part of foot with a rawhide covering. Between the wooden part J and the rubber K at the toe part, layers of canvas and sole leather are placed to prevent breaking or turning up of the toe. ”

“ From one to two months are required to secure union in a broken leg in adults, and from three to five months elapse before the limb is completely serviceable. In children the time requisite for a cure is usually much shorter.
ANKLE-JOINT FRACTURE.
First Aid Rule.—One or both bones of leg may be broken just above ankle. Foot is generally pushed or bent outward. Prepare two pieces of thin wood, four inches wide and long enough to go from sole of foot to just below knee:—the splints. Pad them with folded towels or pieces of blanket. ”

“ The pain which is felt at first a little behind the hip-joint steadily increases in severity and extends along the course of the nerve and its branches in many instances as far as the toes. The specially painful points are about the knee and ankle joints; besides which a feeling of numbness is experienced throughout the whole limb. In severe cases all movement of the limb aggravates the pain, and the patient is obliged to remain in bed. In prolonged attacks the limb may waste and be drawn up and fixed in one position. ”

“ This joint is formed by a polished glass ball plying in a socket of vulcanite, the foot and ankle being joined together with four tendons, passing through rubber springs in the ankle; this joint admits of every motion the natural ankle has. In walking on the side of a hill or inclined plane, or where the foot is used to brace the body, the ankle flexes laterally and the foot remains flat on the ground, thus giving a firm base of support. ”

“ A few rapid upward strokings with some force complete the treatment of the part, and the ankle is next dealt with. The joint is moved in every possible direction, slowly but firmly, the crevices between the articulating bones sought out and kneaded with the finger-tips, and the foot and ankle are then carefully covered. ”

“ The Foot is very rarely dislocated from the leg without fracture of the malleoli. Its reduction requires simple extension of the foot on the leg, with the [Pg 111] knee bent; the surgeon grasps the heel in one hand, the foot in the other, while an assistant fixes the thigh in the half-bent position. The foot is first drawn downwards to disengage it from the tibia, and then directed into its place.
After reduction the limb should be put in a McIntyre’s splint, in the way described for fracture of the tibia near the ankle-joint. ”

“ It is generally occasioned by a fall, the foot or hand coming awkwardly to the ground, the muscles being at the time relaxed and unprepared; by over-exertion in lifting heavy weights; by entanglement and twisting of the limb, &c. The ankle is often sprained by what is called a false step; the fore part of the foot comes in contact with an obstacle unexpectedly, the foot is twisted under the limb, the weight of the body is thrown on the apparatus of one side of the joint, and this is in consequence immoderately and unnaturally stretched. ”

“ The McIntyre’s Splint may be used either bent or straight, whichever position of the knee most relaxes the tension of the muscles on the fragments. As a general rule the straight position is best if the fracture is high up, and the bent one, when near the ankle joint. ”

“ Before performing arthrodesis, the surgeon must decide whether the patient will be better off with a stiff joint or with a weak and movable ankle supported by apparatus. This is often a matter of social position; in the poor, an ankylosed joint is more useful and less expensive. An arthrodesis should seldom be performed at the ankle until the child has passed his eighth year, or at the knee until he has reached his twentieth year. ”

“ Painting the knee with tincture of iodine in spots as large as a silver dollar is also of service at this time. The knee should not be bent in walking until it can be moved by another person without producing discomfort.
Such treatment may be applied to the other joints in a general way. The elbow must be fixed by a splint as recommended for dislocation of the joint (p. 128) . The ankle is treated as advised for sprain of that joint (p. 68) . When a physician can be obtained no layman is justified in attempting to treat a case of water on the knee or similar affection of other joints. ”

“ The ankle- and elbow-joints suffer much less commonly than the knee. The effusion into the articulation takes place insidiously, although rapidly producing considerable enlargement of and fluctuation in the joint, without local heat, redness, or tenderness, and often with but little or no pain or pyrexia. ”

“ The joints of the body always show some changes. The epiphyses are enlarged to a variable degree, resembling the epiphyses typical of human rickets. As in infants, this change is met with most commonly at the wrist joint, involving the ulna and the radius. The knee-joint is likewise often involved, especially the ends of the tibia; the elbow, ankle, and the shoulder may also show an articular swelling of the bones. About these joints hemorrhages in the subcutaneous tissues may be seen, or edema extending along the extremities. ”

“ Conditions, Etc.—This condition, which may affect almost any freely movable joints, as the knee, elbow, ankle, and hip, is commonly caused by a wrench, blow, or fall. Occasionally it comes on without any apparent cause, in which case there is swelling and but slight pain or inflammation about the joint. We shall speak of synovitis of the knee ("water on the knee") , as that is the most common form, but these remarks will apply almost as well to the other joints. In severe cases there are considerable pain, redness and heat, and great swelling about the knee. ”

“ If the ankle or knee be sprained the patient must go to bed for at least twenty-four hours, and give the limb a complete rest.
When the wrist or shoulder is sprained the arm should be confined in a sling. In the more serious cases the injured joint should be fixed in a splint before bandaging. An injured elbow joint is held at a right angle by a pasteboard splint, a bandage, and a sling, while the knee and wrist are treated with the limb in a straight line, as far as possible. ”

“ In the region of the ankle, wrist, and joints of the thumb, however, compound dislocation is sometimes met with uncomplicated by other lesions. The great risk is infection, which may result in serious impairment of the usefulness of the joint or even in its complete destruction, results towards which the concomitant injuries materially contribute. In many instances where infection has occurred, ankylosis is the best result that can be hoped for. ”

“ The lameness of ringbone is characteristic in that the heel is first placed on the ground when the disease is in a fore leg, and the ankle is kept as rigid as possible. In the hind leg, however, the toe strikes the ground first, when the ringbone is high on the ankle, just as in health, but the ankle is maintained in a rigid position. If the bony growth is under the front tendon of the hind leg, or if it involves the coffin joint, the heel is brought to the ground first. ”

“ A rod, attached to the side of the sole beneath the ankle, reaches up the limb, to which it is secured by one broad band and buckle below, and by a second above the knee, opposite which joint the iron stem moves on a free joint backwards and forwards. Opposite the malleoli are set the centres of movement required for the restoration of the deformity; they are moved by a key. The foot is fastened to the sole by straps across the instep and ankle; the toes are restrained by a strap passing round them and fixed to a horizontal toe-bar by the side of the foot. ”

“ Treatment of Deformities resulting from Antecedent Diseases of the Knee.—Flexion is the commonest of these; when due to contracture of the soft parts, these are either stretched by degrees, the limb being encased in plaster after each sitting, or they are divided by open dissection in the popliteal space. If there is fibrous or osseous ankylosis, the choice lies between arthroplasty, the removal of a wedge of bone which includes the joint, or, in patients who are still growing, of a wedge from the femur above the level of the epiphysial cartilage. ”

“ The leg fails to grow, the deformity becomes more pronounced, and the toes become pointed. If the tibia is markedly bent, it may be straightened by osteotomy; and the tendons, Achillis and peronei, may require to be lengthened. If the ankle is unstable as a result of the absence of the lateral malleolus, it may be artificially ankylosed, or the lower end of the tibia may be split vertically so as to make a socket for the talus. In either case, the foot is placed in the equinus attitude to compensate for the shortening of the leg. ”

“ Hence any deviation from this line, one way or the other, indicates more or less dislocation of the tibia. There is a pellet of fat under the ligament, which answers a ‘packing’ purpose—sinking in when the knee is bent; rising when the knee is extended, and bulging on either side of the tendon, almost enough to give the feel of fluctuation.
In a well-formed leg the ligamentum patellæ, the tubercle [Pg 51] of the tibia, and the middle of the ankle should be in the same straight line. ”

“ The tibial collateral ligament, and through it the coronary ligament, are thus gradually stretched, so that the cartilage becomes less securely anchored, and is rendered liable to be displaced towards the centre of the joint during some sudden movement which combines flexion of the knee with medial rotation of the femur upon the tibia, as, for example, in rising quickly from a squatting position, or turning rapidly and pushing off with the foot, in the course of some game such as football or tennis. ”

“ He may fall to the ground and be unable to rise. On examination, the knee is found to be fixed in a slightly flexed position; and while the surgeon may be able to carry out movements of flexion to a considerable extent without increasing the pain, any attempt to extend the joint completely is extremely painful. Tenderness may be elicited on making pressure to the medial side of the ligamentum patellæ in the groove between the femur and the tibia, but the meniscus cannot be recognised by palpation. Considerable effusion rapidly takes place into the synovial cavity. ”

“ Later, he was sent home, and eight months after the reception of the injury his condition was as follows:
Left lower limb somewhat wasted, a diminution of 1 inch in the circumference of the leg and 1/2 an inch in the thigh being found. The patient walks with foot-drop, and the flexor muscles of the knee are weak. On examination the peroneal muscles reacted but sluggishly to faradic irritation. There is complete anæsthesia of the foot to above the ankle, and up to the knee tactile sensation and appreciation of pain were dulled. ”

“ Sprains of the knee are comparatively common as a result of sudden twisting or wrenching of the joint. In addition to the stretching or tearing of ligaments, there is usually a considerable effusion of fluid into the synovial cavity, and examination with the X-rays occasionally reveals that a portion of bone has been torn away with the ligament—sprain-fracture. The swelling fills up the hollows on either side of the patella, and extends for some distance in the synovial pouch underneath the quadriceps. ”

“ The ankylosing type of chronic arthritis is fortunately much rarer than those described above, and is chiefly met with in the joints of the fingers and toes and in those of the vertebral column. The synovial membrane proliferates, grows over the cartilage, and replaces it, and when two such articular surfaces are in contact they tend to adhere, thus obliterating the joint, cavity, and resulting in fibrous or bony ankylosis. ”