Emergency Medicine

314 Orthopaedic Emergencies

INJURIES TO THE LOWER TIBIA, ANKLE AND FOOT

Rupture of the tendo Achilles

DIAGNOSIS

1 This injury is most common in middle-aged men following abrupt muscular

activity. There is pain and weakness of plantar f lexion, although some is still

possible by the long toe flexors. However, the patient is unable to walk on

tiptoe.

2 Feel for a palpable gap in the tendon, although this rapidly fills with blood

and may then disappear.

3 Perform the ‘calf squeeze’ test. This demonstrates reduced or absent foot

plantar f lexion compared with the uninjured side.

(i) It is best performed with the patient kneeling on a chair with

both feet hanging free over the edge.

(ii) Squeeze the unaffected calf just distal to its maximal girth, and

compare the reduced flexion response in the injured leg with the

normal plantar flexion response elicited in the uninjured leg.

MANAGEMENT

1 Apply a below-knee posterior plaster with the ankle in equinus (plantar

f lexed) in the first instance.

2 Give the patient analgesics and refer to the orthopaedic team for a decision

on operative repair or conservative treatment.

Mid-tarsal dislocations

DIAGNOSIS

1 These follow a twisting injury to the forefoot, causing pain and swelling

around the talonavicular and calcaneocuboid mid-tarsal joint.

2 Request a foot X-ray to show disruption of the mid-tarsal joint, often associ-

ated with fractures of the navicular, cuboid, talus or calcaneus. These may

merely be avulsion f lake fractures.

3 Arrange a CT scan to evaluate these complex injuries further.

MANAGEMENT

1 Give the patient analgesics, elevate the foot and refer to the orthopaedic team.

Metatarsal injuries and tarsometatarsal dislocations

DIAGNOSIS

1 These are caused by direct trauma, crushing or twisting.

2 A transverse avulsion fracture of the base of the fifth metatarsal often accom-

panies an ankle inversion injury, at the site of insertion of peroneus brevis.