Foot examination Based on the book by N.A. Koryshkov "Foot Trauma" Anamnestic data and the results of an external examination are still quite significant when making a diagnosis. For example, in 75% of cases, calcaneal fractures are the result of a fall from a height. The importance of an external examination remains a priority, and the interpretation of clinical manifestations directly depends on the medical experience, which can suggest a series of additional studies visualizing clinical symptoms. A properly performed palpation examination will help determine the depth and localization of the pathological process. Examination of both limbs is performed from the dorsal and plantar surfaces, determining the axis of the rear and forefoot. When the bones of various parts of the foot are damaged, characteristic deformations, changes in alignment and corresponding complaints are found. The following symptoms are characteristic of damage to the bones of various parts of the foot: - "pear-shaped" deformity of the heel area - an increase in the diameter (expansion) and a decrease in its height, as well as valgus deviation of the calcaneus; — Barsky's symptom: spread of hematoma from the site of fracture of the calcaneal tuberosity with subsequent imbibition of soft tissues in the middle of the non-load-bearing plantar surface; — compression test of the hindfoot, performed with both hands of the examiner, taken in a "lock"; — Jacobson's symptom: pressure from the plantar side on the head of the metatarsal bone causes pain at the fracture site; — push symptom: pain in the area of ??the fracture appeared or intensified by pulling on the corresponding toe, as well as by tapping on the head of the metatarsal bone; — Yaralov-Yaralyanets symptom: sharp pain arising from downward bending of the corresponding toe with a fixed forefoot indicates a fracture of the metatarsal bone; — Meleshevich's sign: the lower third of the patient's leg is immobilized with the left hand while the first finger of the right hand is bent and stroked along the plantar surface of the foot along the axis of each metatarsal bone from the heel to the toes. The onset of pain localizes the fracture. — Momburg's sign: the foot is placed on a hard surface. When pressure is applied to the head of the fractured metatarsal bone, the nail phalanx of the corresponding toe rises upward. The degree of tissue tension in the foot and the temperature of the skin are determined by palpation. Pulsation of the dorsalis pedis and posterior tibial arteries is mandatory. In some patients, deformity caused by foot enlargement, in a volume inconsistent with radiographic data, is noticeable. An assessment of the condition of the peripheral vessels and skin in these patients allows one to suspect direct or indirect vascular injury. To objectively assess circulatory disorders manifested by increased volume, the foot perimeter can be measured at the base of the metatarsal bones and the dynamic edema index (DEI) can be calculated. To determine the magnitude of forefoot deformity, we used a technique involving drawing a line through the midpoint of the Achilles tendon, the center of the calcaneal tuberosity, and the plantar surface of the foot. Normally, this line should project along the head of the first metatarsal bone. A lateral deviation of this line indicates forefoot supination, while a medial deviation indicates pronation. When examining the hindfoot, a line was drawn through the center of the calcaneal tendon. Normally, this line passes through the center of the calcaneal tuberosity. A lateral deviation of the line from the center of the calcaneal tuberosity indicates varus deformity of the hindfoot, while a medial deviation indicates valgus deformity. Passive ankle joint movements were measured using a standard goniometer. Considering that the axis of rotation of the ankle joint practically coincides with the apex of the lateral malleolus (Yu. A. Veisman, A. K. Latsis, 1982; T. Verne, I. Man, R. Man, 1978), we compared the center of the goniometer with the apex of the lateral malleolus. The average amplitude of motion in the norm, according to M. O. Fridland (1954), I. V. Fishkin (1986), is 63.1 - 1.2 (flexion - 45.3 - 1.0, extension - 17.8 - 0.6). Hematoma of the fascial sheaths, imbibing the tissues of the plantar surface of the foot, will be an objective clinical sign of damage to its various sections. There is various information on this matter in the literature. L. Bohler (1937) described the clinical picture of a calcaneus fracture as follows: "...inability to walk, swelling in the heel area, an increase in its volume, and subcutaneous hemorrhage spreading toward the sole, which is never observed in ankle fractures." D. I. Cherkes-Zade and Yu. F. Kamenev (1995) considered the symptom of an "isolated hematoma" of the plantar region, described by V. L. Barsky (1987), to be a clinical sign of a fracture of the tuberosity of the calcaneus, both with and without displacement of fragments. More accurate are the topographic and anatomical data reported by V. F. Voyno-Yasenetsky back in 1934 on the routes of pus spread in deep phlegmons of the foot. This is analogous to the penetration of blood from sites of calcaneus fractures and provides the basis for a hematoma of the deep fascial spaces of the foot and lower leg. An excellent description of this anatomical structure is given in the chapter "Foot Phlegmons": "...the calcaneal canal, canalis calcanei Richet, also called canalis malleolaris, is of great importance in the pathology of foot phlegmons. Let us therefore dwell on some features of its anatomy that are especially important for us. Its outer wall, or rather, floor, is formed by the medial surface of the calcaneus, which is concave in the form of a wide groove, and the sustentaculum tali. The inner wall is formed by the lig. laciniatum. The capsule of the ankle joint and the posterior edges of the medial malleolus and the calcaneus can be considered the anterior wall of the canal. The superior border of the canalis calcanei does not exist, since it continues directly into the posterior deep fascial space of the leg..." From the above description, it can be concluded that one of the obligatory fracture lines of the calcaneus in intra-articular displaced fractures will always destroy the inner wall of the Richet canal along its course. The escaping blood will move distally into the medial fascial bed of the sole (which was partially noted by Barsky), and proximally towards the posterior parts of the ankle joint capsule and the deep fascial spaces of the lower third of the leg. We observed this during imbibition of blood in the soft tissues of the distal third of the leg in the space between the inner edge of the Achilles tendon and behind the medial malleolus. Our observations indicate that this symptom is pathognomonic for various types of fractures of the ankles (Fig. 2.1), calcaneus and talus (Figs. 2.2, 3.18, 3.30) and the bones of the middle and forefoot (Figs. 4.53, 5.8, 6.25). [ /upload/medialibrary/0f5/artro_1.jpg ] Fig. 2.1. Photo of the plantar surface of the left foot of patient M. E. V-v and an X-ray of his pronation fracture-dislocation in the ankle joint [ /upload/medialibrary/81e/artro_2.jpg ] Fig. 2.2. Photo of the plantar surface of the right foot of patient M. Yu. V-v and X-ray of the marginal extra-articular fracture of the calcaneal tuberosity on the medial surface The most common cause of foot injury is a high-energy impact - a heavy object or a fall from a height. Typical signs and symptoms include pain, swelling, and difficulty putting weight on the foot. Clinically, these injuries manifest themselves from minor sprains to fracture-dislocations. During examination, it is necessary to localize the area of ????the greatest pain, which will determine the targeted use of radiological diagnostic methods. Injuries with minimal radiographic information present a difficulty in diagnosis, which is fully characteristic of midfoot injuries, due to the small size of bone formations and the complexity of joint lines. Pain occurs upon palpation along the multifaceted tarsometatarsal joint and radiates medially and laterally to the site of force application. External manifestations of the pathology include a hematoma of the medial fascial bed of the plantar fascia and swelling of the foot. Radiographic data may be absent, or, compared with other values, a slight widening of the joint spaces and/or interosseous spaces may be revealed, confirming the presence of a severe sprain or a fracture without displacement of the fragments. We call this clinical situation an "incomplete" fracture-dislocation in the Lisfranc joint. A repeat examination is necessary if swelling and pain persist for more than 10 days after the injury. By this time (2-3 weeks), resorption along the fracture lines may appear and will not be more visible on conventional radiography. In the acute phase, computed tomography of the foot in coronal and horizontal projections is advisable (Fig. 2.3). [ /upload/medialibrary/7ad/artro_3.jpg ] Fig. 2.3. Photo of the plantar surface of the right foot of patient K-n M.V., radiographs in the frontal and 3/4 projections do not provide information on the presence of a fracture. CT reveals fractures of the bases of the I, II, III, I metatarsal bones on the right.