FRACTURES AND DISLOCATIONS OF THE MIDFOOT AND FOREFOOT

FRACTURES AND FRACTURES AND DISLOCATIONS OF THE DISLOCATIONS OF THE

MIDFOOT AND MIDFOOT AND FOREFOOTFOREFOOT

DR. KRISHNA MADHUKAR .D DR. KRISHNA MADHUKAR .D

Anatomical divisions of the footAnatomical divisions of the foot

Navicular FracturesNavicular Fractures

Anatomy Anatomy - Keystone of the medial longitudinal arch of the footKeystone of the medial longitudinal arch of the foot

- Medial Prominence – navicular tuberosity provides insertion Medial Prominence – navicular tuberosity provides insertion to the Tibialis posterior.to the Tibialis posterior.

- Proximal articular surface articulates with the TalusProximal articular surface articulates with the Talus

- Distal articular surface articulates with the 3 cuneiform bones.Distal articular surface articulates with the 3 cuneiform bones.

- Laterally articulates with the cuboid.Laterally articulates with the cuboid.

- Spring and superficial deltoid ligaments provide strong Spring and superficial deltoid ligaments provide strong support to plantar and medial aspect of talonavicular joint.support to plantar and medial aspect of talonavicular joint.

- Calcaneonavicular ligament supports lateral and dorsal aspects Calcaneonavicular ligament supports lateral and dorsal aspects of talonavicular joint.of talonavicular joint.

- Blood supply – Dorsalis pedis and medial plantar arteries by Blood supply – Dorsalis pedis and medial plantar arteries by radial distribution .radial distribution .

- Perfusion is abundant along the periphery but is avascular Perfusion is abundant along the periphery but is avascular centrally.centrally.

Sangeorzan classificationSangeorzan classification

A)A) Avulsion type fractureAvulsion type fracture

Can involve either Can involve either talonavicular or talonavicular or naviculocuneiform naviculocuneiform ligamentsligaments

B) Tuberosity fractures B) Tuberosity fractures

Traction type injuries Traction type injuries with disruption of with disruption of Tibialis posterior Tibialis posterior insertion without joint insertion without joint surface disruptionsurface disruption

C)C)

TYPE 1 TYPE 1

Body fracture splits the Body fracture splits the navicular into dorsal navicular into dorsal and plantar segments.and plantar segments.

C)C)

TYPE 2TYPE 2

Body fracture spilts the Body fracture spilts the navicular into medial navicular into medial and lateral segmentsand lateral segments

C) C)

TYPE 3TYPE 3

Body fracture Body fracture distinguished by distinguished by communition of the communition of the fragments and fragments and significant displacement significant displacement of the medial and lateral of the medial and lateral parts.parts.

Treatment Treatment

Two criteria important in obtaining Two criteria important in obtaining satisfactory outcome.satisfactory outcome.

a)a) Maintanence and restoration of the medial column length.Maintanence and restoration of the medial column length.

b)b) Articular congruity of the talonavicular joint.Articular congruity of the talonavicular joint.

Closed management of Navicular Closed management of Navicular fractures fractures

IndicationsIndications

- Less than 2mm displacement of the talonavicular joint surface.Less than 2mm displacement of the talonavicular joint surface.

- No evidence of mid foot instability.No evidence of mid foot instability.

- No loss of bony length.No loss of bony length.

Treatment by closed management.Treatment by closed management.

Short leg NWB cast for 6 – 8 wks.Short leg NWB cast for 6 – 8 wks.

Recheck stability with stress views after 10 days from Recheck stability with stress views after 10 days from injuryinjury

Progressive weight bearing in protective brace untill Progressive weight bearing in protective brace untill

asymptomaticasymptomatic..

Operative management of Navicular Operative management of Navicular Fractures.Fractures.

Priority of fixationPriority of fixation

- Maintain position of the Navicular in the foot- Maintain position of the Navicular in the foot

- Preserve Talonavicular congruity.- Preserve Talonavicular congruity.

- Restore attachment of the Posterior tibialis tendon- Restore attachment of the Posterior tibialis tendon

- Preserve naviculocuniform articulations.- Preserve naviculocuniform articulations.

FixationFixation

1)1) Stabilization of Stabilization of

individual fragments individual fragments

accomplished by 2.7, 3.5, accomplished by 2.7, 3.5,

4.0 mm SCREW 4.0 mm SCREW

FIXATIONFIXATION

2) Restoration of medial 2) Restoration of medial

column length in column length in

communited fractures communited fractures

by external fixation or by external fixation or

internal plating to internal plating to

protect the reduction protect the reduction

and prevent excess joint and prevent excess joint

motion until the fracture motion until the fracture

stabitizes.stabitizes.

3) Liberal use of 3) Liberal use of

cancellous or cancellous or

corticocancellous graft corticocancellous graft

to fill structural defects.to fill structural defects.

4) If greater than 40% of Talonavicular joint 4) If greater than 40% of Talonavicular joint

articular surface cannot be reconstructed an articular surface cannot be reconstructed an

acute Talonavicular fusion should be done to acute Talonavicular fusion should be done to

preserve foot alignment.preserve foot alignment.

Post operative carePost operative care

Below knee cast with foot in plantigrade Below knee cast with foot in plantigrade position.position.

Non Weight bearing for 8 wksNon Weight bearing for 8 wks Progressive weight bearing as tolerated at 8 Progressive weight bearing as tolerated at 8

wks.wks. Supportive brace until pain free full weight Supportive brace until pain free full weight

bearing is achieved.bearing is achieved.

ComplicationsComplications

Non union.Non union. Arthritic degeneration.Arthritic degeneration. Late instability.Late instability. Bony resorption with loss of normal foot Bony resorption with loss of normal foot

alignment.alignment. Collapse and avascular necrosis.Collapse and avascular necrosis.

NAVICULAR DISLOCATIONNAVICULAR DISLOCATION

Dislocation or subluxation of the navicular is Dislocation or subluxation of the navicular is rare.rare.

Dislocates medial and plantar to its normal Dislocates medial and plantar to its normal position in neuropathic instabiltyposition in neuropathic instabilty

Dislocates dorsal in acute trauma Dislocates dorsal in acute trauma

Trauma mechanismTrauma mechanism Initial hyperplantar flexion of the forefoot with subsequent Initial hyperplantar flexion of the forefoot with subsequent

axial loadingaxial loading

Ligamentous disruptions in dorsal and plantar Ligamentous disruptions in dorsal and plantar Naviculocuneiform ligaments.Naviculocuneiform ligaments.

Dislocation in neuropathic foot is due to motor pull with Dislocation in neuropathic foot is due to motor pull with ligamentous failure.ligamentous failure.

Tibialis posterior pulls the navicular plantar and medial to the Tibialis posterior pulls the navicular plantar and medial to the foot.foot.

Treatment for dislocationTreatment for dislocation

Similar to that advocated in fracture Similar to that advocated in fracture management.management.

CUBOID FRACTURESCUBOID FRACTURES

Applied Anatomy.Applied Anatomy.- Part of lateral column support of the foot.Part of lateral column support of the foot.

- Proximal saddle shaped articulation with the Calcaneum acts as a stress valve for Proximal saddle shaped articulation with the Calcaneum acts as a stress valve for imperfectly matched movements of the Talonavicular and subtalar joints.imperfectly matched movements of the Talonavicular and subtalar joints.

- Distally articulates with 4Distally articulates with 4thth and 5 and 5thth metatarsals. metatarsals.

- Variable articulations with navicular and lateral cuneiform on the dorsomedial Variable articulations with navicular and lateral cuneiform on the dorsomedial aspect of cuboid.aspect of cuboid.

- Peroneus longus courses along the lateral and plantar surfaces of the Cuboid on its Peroneus longus courses along the lateral and plantar surfaces of the Cuboid on its way to the base of the 1way to the base of the 1stst metatarsal. metatarsal.

Mechanism of injuryMechanism of injury

Forced plantar flexion Forced plantar flexion and abduction causing a and abduction causing a compressive load along compressive load along the long axis of the the long axis of the cuboid.cuboid.

‘ ‘NUT CRACKER FRACTURE’NUT CRACKER FRACTURE’

Closed management of Cuboid Closed management of Cuboid fracturesfractures

INDICATIONSINDICATIONS- Less than 2mm displacement of the Less than 2mm displacement of the

Calcaneocuboid or Cuboid metatarsal joint Calcaneocuboid or Cuboid metatarsal joint surface.surface.

- No evidence of Cuboid subluxation No evidence of Cuboid subluxation - No loss of bony length. No loss of bony length.

TREATMENTTREATMENT- Below knee cast with NWB for 6-8 wks.Below knee cast with NWB for 6-8 wks.

- Recheck stability with stress views at 10 days of Recheck stability with stress views at 10 days of injury.injury.

- Progressive weight bearing in protective brace until Progressive weight bearing in protective brace until asymptomatic after 8 wks.asymptomatic after 8 wks.

Operative TreatmentOperative Treatment

GOALSGOALS- Restoration of the lateral column lengthand plantar Restoration of the lateral column lengthand plantar

support of the mid foot.support of the mid foot.

- Mobility of the Tarsometatarsal joints.Mobility of the Tarsometatarsal joints.

- Articular integrity of Calcaneocuboid joint.Articular integrity of Calcaneocuboid joint.

2.7 and 3.5mm cortical 2.7 and 3.5mm cortical lag screws are used lag screws are used across the fracture plane across the fracture plane in simple longitudinal in simple longitudinal fractures. fractures.

Small external fixation Small external fixation to restore lateral column to restore lateral column length in displaced and length in displaced and compressed fractures.compressed fractures.

- 2 pins distal calcaneum2 pins distal calcaneum- 1 pin each in the 41 pin each in the 4thth and and

55thth metatarsal bases. metatarsal bases.

Post Operative carePost Operative care

Below knee cast in neutral and plantigrade Below knee cast in neutral and plantigrade position for 6 wks.position for 6 wks.

Reduction pins and external fixator are Reduction pins and external fixator are removed at 6 wks.removed at 6 wks.

After 6wks – NWB, removable splint, self After 6wks – NWB, removable splint, self directed ROM exercises through ankle and directed ROM exercises through ankle and subtalar joints.subtalar joints.

Wt bearing after 10 wks.Wt bearing after 10 wks.

CUBOID DISLOCATIONCUBOID DISLOCATION

Isolated subluxation or dislocation is rare.Isolated subluxation or dislocation is rare.

Painful subluxation termed as ‘CUBOID Painful subluxation termed as ‘CUBOID SYNDROME’ has been reported in 9% of SYNDROME’ has been reported in 9% of high performance atheletes and 17% of high performance atheletes and 17% of professional ballet dancersprofessional ballet dancers

Symptoms of Cuboid Syndrome Symptoms of Cuboid Syndrome

Lateral foot pain radiating to anterior ankle, Lateral foot pain radiating to anterior ankle, fourth ray or plantar aspect of the mid foot.fourth ray or plantar aspect of the mid foot.

Weakness in forefoot push off.Weakness in forefoot push off.

Findings in Cuboid SyndromeFindings in Cuboid Syndrome

Reduction in dorsolateral to plantar medial Reduction in dorsolateral to plantar medial mobility through Calcaneocuboid joint.mobility through Calcaneocuboid joint.

Peroneus longus spasm.Peroneus longus spasm.

Pain with pressure applied to the plantar aspect Pain with pressure applied to the plantar aspect of the cuboid.of the cuboid.

The position of The position of

dislocated cuboid is dislocated cuboid is

always plantar and always plantar and

medial.medial.

TreatmentTreatment

No rotation or subluxation – managed closed.No rotation or subluxation – managed closed.

Open reduction and internal fixation with k Open reduction and internal fixation with k wires or screws trough the lateral cuneiform wires or screws trough the lateral cuneiform into the cuboid is advised.into the cuboid is advised.

K – wires are removed after 4 wks with NWB.K – wires are removed after 4 wks with NWB.

INJURY TO THE OS PERONEUMINJURY TO THE OS PERONEUM

Os Peroneum is a sesamoid lying within the Os Peroneum is a sesamoid lying within the substance of the Peroneus longus tendon.substance of the Peroneus longus tendon.

It is found at the level of the Cuboid tunnel where the It is found at the level of the Cuboid tunnel where the Peroneus longus tendon passes under the Cuboid or at Peroneus longus tendon passes under the Cuboid or at the level of the Calcaneocuboid joint.the level of the Calcaneocuboid joint.

Present in 5 – 14 % of the population.Present in 5 – 14 % of the population.

Mode of injuryMode of injury

Injury to this bone can Injury to this bone can be caused by direct be caused by direct blow or supination and blow or supination and plantar flexion forces plantar flexion forces that cause tensile loads that cause tensile loads across the bone. across the bone.

TreatmentTreatment

NWB cast for minimal of 6wks.NWB cast for minimal of 6wks.

Progressive weight bearing in a cast until Progressive weight bearing in a cast until asymptomatic.asymptomatic.

If painful fibrous union occurs excision of the bone If painful fibrous union occurs excision of the bone ligaments to be done.ligaments to be done.

Cuneiform InjuriesCuneiform Injuries

AnatomyAnatomy

- - Three cuneiforms are present in the middle of the medial Three cuneiforms are present in the middle of the medial column of the foot and support the medial longitudinal arch.column of the foot and support the medial longitudinal arch.

- All are wedge shaped along the axial axis.All are wedge shaped along the axial axis.

- Medial cuneiform has plantar base and dorsal crest where as Medial cuneiform has plantar base and dorsal crest where as middle and lateral cuneiforms have dorsal bases and plantar middle and lateral cuneiforms have dorsal bases and plantar crests.crests.

- Proximally each cuneiform articulates with 1/3 of the Proximally each cuneiform articulates with 1/3 of the distal navicular and distally articulate with the distal navicular and distally articulate with the respective metatarsals.respective metatarsals.

- Between each of the 2 cuneiform pairs there are 3 Between each of the 2 cuneiform pairs there are 3 distinct connecting ligaments.distinct connecting ligaments.


Cuneiform fractures are Cuneiform fractures are

due to indirect axial due to indirect axial

loading of the bone.loading of the bone.

Commonly seen in conjunction with Tarsometatarsal Commonly seen in conjunction with Tarsometatarsal injuries.injuries.

Fracture or fracture dislocation of these bones signify Fracture or fracture dislocation of these bones signify severe ligamentous injury of the mid foot.severe ligamentous injury of the mid foot.

Medial cuneiform instability usally occurs with Medial cuneiform instability usally occurs with minimal energy.minimal energy.

A noticeable increase in A noticeable increase in the size of the first web the size of the first web space is reported in space is reported in isolated medial isolated medial cuneiform injury.cuneiform injury.

‘ ‘GAP SIGN’GAP SIGN’

TreatmentTreatment

Closed ManagementClosed ManagementIndicationsIndications

. No evidence of instability with wt bearing or stress x-rays.. No evidence of instability with wt bearing or stress x-rays.

. No loss of bony length.. No loss of bony length.

TreatmentTreatment

. NWB below knee cast for 6-8 wks.. NWB below knee cast for 6-8 wks.

. Progressive weight bearing in protective brace until . Progressive weight bearing in protective brace until asymptomaticasymptomatic

Surgical managementSurgical management

Non anatomic reduction Non anatomic reduction or continued instability or continued instability should be treated with should be treated with open reduction and pin open reduction and pin and screw fixation into and screw fixation into adjacent stable adjacent stable structures.structures.

Use of corticocancellous grafts for any Use of corticocancellous grafts for any evidence of bony crush.evidence of bony crush.

Instability of medial cuneiform requires Instability of medial cuneiform requires internal fixation even if anatomic reduction is internal fixation even if anatomic reduction is obtained through traction.obtained through traction.

Unstable articulations require intercuneiform Unstable articulations require intercuneiform and naviculocuneiform fusion. and naviculocuneiform fusion.

Lisfranc’s Joint InjuriesLisfranc’s Joint Injuries

Any bony or ligamentous injury involving the Any bony or ligamentous injury involving the tarsometatarsal joint complex.tarsometatarsal joint complex.

Named after the Napoleonic-era surgeon who Named after the Napoleonic-era surgeon who described amputations at this level without described amputations at this level without ever defining a specific injury.ever defining a specific injury.

AnatomyAnatomy

Lisfranc’s joint: articulation Lisfranc’s joint: articulation between the 3 cuneifoms between the 3 cuneifoms and cuboid (tarsus) and the and cuboid (tarsus) and the bases of the 5 metatarsals.bases of the 5 metatarsals.

Osseous stability is Osseous stability is provided by the Roman arch provided by the Roman arch

of the metatarsalsof the metatarsals..

AnatomyAnatomy

Lisfranc’s ligamentLisfranc’s ligament: : large oblique ligament large oblique ligament that extends from the that extends from the plantar aspect of the plantar aspect of the medial cuneiform to the medial cuneiform to the base of the second base of the second metatarsal. (there is metatarsal. (there is nono transverse metatarsal transverse metatarsal ligament from 1 to 2)ligament from 1 to 2)

AnatomyAnatomy

Interosseous ligaments Interosseous ligaments extend from the 2extend from the 2ndnd to to 55thth metatarsal bases on metatarsal bases on the dorsal and plantar the dorsal and plantar aspects.aspects.

Secondary stabilizers: Secondary stabilizers: plantar fascia, plantar fascia, peroneus longus, and peroneus longus, and intrinsincsintrinsincs

AnatomyAnatomy

Associated Structures:Associated Structures:

1. Dorsalis pedis artery – 1. Dorsalis pedis artery – courses between 1courses between 1stst and and 22ndnd metatarsal bases metatarsal bases

2. Deep peroneal nerve: 2. Deep peroneal nerve: runs alongside the arteryruns alongside the artery

Mechanisms of InjuryMechanisms of Injury

Trauma: motor vehicle accidents account for one Trauma: motor vehicle accidents account for one third to two thirds of all cases (incidence of lower third to two thirds of all cases (incidence of lower extremity foot trauma has increased with the use of extremity foot trauma has increased with the use of air bags)air bags)

Crush injuriesCrush injuries

Sports-related injuries are also occurring with Sports-related injuries are also occurring with increasing frequencyincreasing frequency

Mechanisms of Injury - DirectMechanisms of Injury - Direct

- Direct Injuries: force is applied directly to the Lisfranc’s articulation. The applied force is to the dorsum of the foot.

- Plantar displacement is more common, but dorsal displacement can also occur

Mechanisms of Injury - IndirectMechanisms of Injury - Indirect

Indirect injuries are more common than direct and result from axial loading or twisting. Metatarsal bases dislocate dorsally more often than plantarly.

Associated FracturesAssociated Fractures

Base of 2Base of 2ndnd metatarsal metatarsal

Avulsion of navicularAvulsion of navicular

Isolated medial Isolated medial cuneiformcuneiform

CuboidCuboid

ClassificationClassificationQuenu and Kuss (1909)Quenu and Kuss (1909)

HOMOLATERAL: most common


ISOLATED


DIVERGENT: least commom

ClassificationClassificationMyerson (1986)Myerson (1986)

Clinical FindingsClinical Findings

Midfoot pain with Midfoot pain with difficulty in weight difficulty in weight bearingbearing

Swelling across the Swelling across the dorsum of the footdorsum of the foot

Deformity variable due Deformity variable due to possible spontaneous to possible spontaneous reductionreduction

Clinical FindingsClinical Findings

Check neurovascular Check neurovascular status for compromise status for compromise of dorsalis pedis artery of dorsalis pedis artery and/or deep peroneal and/or deep peroneal nerve injurynerve injury

Asses for possible Asses for possible COMPARTMENT COMPARTMENT SYNDROMESYNDROME

TreatmentTreatment

Early recognition is the key to preventing long term Early recognition is the key to preventing long term disabilitydisability

Anatomic reduction is necessary for best results: Anatomic reduction is necessary for best results: displacement of >1mm. or gross instability of displacement of >1mm. or gross instability of tarsometatarsal, intercuneiform, or naviculocuneiform tarsometatarsal, intercuneiform, or naviculocuneiform joints is unacceptablejoints is unacceptable

Goal: obtain or maintain anatomic reductionGoal: obtain or maintain anatomic reduction

TreatmentTreatment

Nonoperative : for Nonoperative : for nondisplaced injuriesnondisplaced injuries

Short leg castShort leg cast 4 to 6 weeks nonweight 4 to 6 weeks nonweight

bearingbearing Repeat x-rays to rule out Repeat x-rays to rule out

displacement as displacement as swelling decreasesswelling decreases

Total treatment 2-3 Total treatment 2-3 monthsmonths

Operative TreatmentOperative Treatment

Surgical emergencies:Surgical emergencies:

1. Open fractures1. Open fractures

2. Vascular compromise 2. Vascular compromise (dorsalis pedis)(dorsalis pedis)

3. Compartment syndrome3. Compartment syndrome

Operative TreatmentOperative TreatmentTechniqueTechnique

1 – 3 dorsal incisions:1 – 3 dorsal incisions:

1. 11. 1stst incision centered at incision centered at TMT joint and along TMT joint and along axis of 2axis of 2ndnd ray, lateral to ray, lateral to EHL tendonEHL tendon

2. Identify and protect NV 2. Identify and protect NV bundlebundle


Reduce and provisionally Reduce and provisionally stabilize 2stabilize 2ndnd TMT joint TMT joint

Reduce and provisionally Reduce and provisionally stabilize 1stabilize 1stst TMT joint TMT joint

If lateral TMT joints remain If lateral TMT joints remain displaced use 2displaced use 2ndnd or 3 or 3rdrd incision(sincision(s

2nd met. Base unreduced

reduced


After achieving After achieving anatomic reduction anatomic reduction positional screw positional screw fixation should be done.fixation should be done.

Case ExampleCase ExamplePre-op AP

Post-op AP

Post-op Lateral

ComplicationsComplications

- Compartment syndrome- Compartment syndrome

- Infection- Infection

- Neurovascular injury- Neurovascular injury

Metatarsal FracturesMetatarsal Fractures

MOI – Direct blow of a heavy object dropped MOI – Direct blow of a heavy object dropped onto the forefoot and torque related metatarsal onto the forefoot and torque related metatarsal shaft fractures.shaft fractures.

Avulsion fractures of the base of the 5Avulsion fractures of the base of the 5 thth metatarsal are common.metatarsal are common.

Stress fractures at 2Stress fractures at 2ndnd and 3 and 3rdrd metatarsal necks metatarsal necks and proximal portion of the shaft of the 5and proximal portion of the shaft of the 5 thth metatarsal are common.metatarsal are common.

11stst Metatarsal fractures Metatarsal fractures

AnatomyAnatomy- Shorter and wider than the other metatarsals.Shorter and wider than the other metatarsals.

- Lack of interconnecting ligament between 1Lack of interconnecting ligament between 1stst and 2 and 2ndnd metatarsals allows independent motion.metatarsals allows independent motion.

- Two powerful motor attachments to its baseTwo powerful motor attachments to its base i) Tibialis anterior – medial aspect of base i) Tibialis anterior – medial aspect of base ii) Peroneus longus – lateral aspect of baseii) Peroneus longus – lateral aspect of base - The head of the 1- The head of the 1stst metatarsal supports 2 sesamoid bones. metatarsal supports 2 sesamoid bones.

TreatmentTreatment

No evidence of instability – closed No evidence of instability – closed management with below knee cast, NWB for management with below knee cast, NWB for 4 – 6 weeks.4 – 6 weeks.

Presence of instability or loss of position of Presence of instability or loss of position of metatarsal head – treated with percutaneous metatarsal head – treated with percutaneous k-wiring or open reduction and screw fixation.k-wiring or open reduction and screw fixation.

Severe midshaft or head communition or open Severe midshaft or head communition or open fracture – external fixation.fracture – external fixation.

Central MetatarsalsCentral Metatarsals

AnatomyAnatomy- The 4 lesser metatarsals are linked to each The 4 lesser metatarsals are linked to each

other at their bases with a series of 3 ligaments other at their bases with a series of 3 ligaments (dorsal,central and plantar) (dorsal,central and plantar)

- Thick transverse metatarsal ligament connects Thick transverse metatarsal ligament connects metatarsals by linking the plantar plate of the metatarsals by linking the plantar plate of the adjacent MTP joints.adjacent MTP joints.

TreatmentTreatment

Fractures with <10 degrees angulation along Fractures with <10 degrees angulation along the long axis or <4 mm translation of shaft are the long axis or <4 mm translation of shaft are treated with closed management with below treated with closed management with below knee cast for 4 – 6 wks (NWB).knee cast for 4 – 6 wks (NWB).

Fractures with > 10 degrees angulation or > 4 Fractures with > 10 degrees angulation or > 4 mm translation of the shaft are treated with mm translation of the shaft are treated with closed reduction. closed reduction.

Rule out instability of the Lisfranc’s joint.Rule out instability of the Lisfranc’s joint.

Intramedullary k-wiring is done if there are Intramedullary k-wiring is done if there are multiple metatarsal fractures with significant multiple metatarsal fractures with significant communition.communition.

Fifth Metatarsal fracturesFifth Metatarsal fractures

AnatomyAnatomy- 55thth metatarsal has major motor insertions at its metatarsal has major motor insertions at its

basebase

i) Peroneus brevis attaches on the dorsal aspect i) Peroneus brevis attaches on the dorsal aspect of the tubercle. of the tubercle.

ii) Peroneus teritius attaches to the dorsal ii) Peroneus teritius attaches to the dorsal aspect of the proximal metaphyseal and aspect of the proximal metaphyseal and diaphyseal junction.diaphyseal junction.


- - Majority of injuries are related to sport or athletic activity.Majority of injuries are related to sport or athletic activity.

- Separated roughly into 2 groups- Separated roughly into 2 groups

a) Proximal base fractures a) Proximal base fractures

b) Distal spiral or dancers fracturesb) Distal spiral or dancers fractures

- Proximal 1/5- Proximal 1/5thth metatarsal fractures are divided by the location metatarsal fractures are divided by the location of the fracture and the presence of prodromal symptoms.of the fracture and the presence of prodromal symptoms.

Avulsion or zone 1 injuryAvulsion or zone 1 injury

Occurs from indirect Occurs from indirect load, sudden inversion load, sudden inversion of the hindfoot with of the hindfoot with weight on the lateral weight on the lateral metatarsal with tension metatarsal with tension along the insertion of along the insertion of the lateral band of the lateral band of plantar aponeurosis. plantar aponeurosis.

Zone 2 injuryZone 2 injury

True Jones fractureTrue Jones fracture

Results from adduction Results from adduction of the forefoot resulting of the forefoot resulting in a fracture at the in a fracture at the proximal metaphyseal proximal metaphyseal diaphyseal junction of diaphyseal junction of the bone.the bone.

Zone 3 injuryZone 3 injury

Proximal diaphyseal Proximal diaphyseal stress fracturestress fracture

Occurs in the proximal Occurs in the proximal 1.5 cm of the shaft of 1.5 cm of the shaft of the metatarsalthe metatarsal

Repetitive cyclic loads Repetitive cyclic loads as seen in high level as seen in high level athletes – mechanism of athletes – mechanism of injuryinjury

TreatmentTreatment

Closed managementClosed management

Zone 1 - weight bearing as tolerated with hard sole Zone 1 - weight bearing as tolerated with hard sole shoe.shoe.

Zone 2 – weight bearing cast for 8 – 10 wksZone 2 – weight bearing cast for 8 – 10 wks

Zone 3 – NWB for 3 months, weight bearing when pain Zone 3 – NWB for 3 months, weight bearing when pain free examination free examination

Surgical Management Surgical Management

Open debridment and axial compression with Open debridment and axial compression with cortical or cannulated sccrew with cancellous cortical or cannulated sccrew with cancellous bone grafting should be done for zone 3 bone grafting should be done for zone 3 injuries with symptomatic non union.injuries with symptomatic non union.

Injury to the first Injury to the first Metatarsophalangeal jointMetatarsophalangeal joint

AnatomyAnatomy- Formed by the head of the 1st metatarsal and - Formed by the head of the 1st metatarsal and

proximal phalanx of the great toe.proximal phalanx of the great toe.

- Stability is provided by the complex structure of the - Stability is provided by the complex structure of the joint capsule and ligaments.joint capsule and ligaments.

- The plantar capsule is a thick weight bearing structure - The plantar capsule is a thick weight bearing structure with strong attachments to the base of proximal with strong attachments to the base of proximal phalanx.phalanx.

- Embeded in the plantar structure are the 2 bones known as - Embeded in the plantar structure are the 2 bones known as sesamoids which articulate directly with the metatarsal head.sesamoids which articulate directly with the metatarsal head.

- Medial and lateral sesamoids are the ground contact points - Medial and lateral sesamoids are the ground contact points for weight bearing for the 1for weight bearing for the 1stst metatarsal. metatarsal.

- Between the 2 sesamoids and plantar to the intersesamoid - Between the 2 sesamoids and plantar to the intersesamoid ligament runs the flexor hallucis longus tendon.ligament runs the flexor hallucis longus tendon.

Multiple intrinsic motor insertions at the Multiple intrinsic motor insertions at the proximal end of this complex control proximal end of this complex control the stability and position of the jointthe stability and position of the joint

i) Medially the medial head of Flexor i) Medially the medial head of Flexor

hallucis brevis inserts into the proximal hallucis brevis inserts into the proximal aspect of the medial sesamoid. aspect of the medial sesamoid.

ii) The Adductor hallucis partially inserts ii) The Adductor hallucis partially inserts the medial sesamoid and continues to the medial sesamoid and continues to insert in the medial plantar tubercle of insert in the medial plantar tubercle of the proximal phalanx.the proximal phalanx.

This motor complex provides resistance This motor complex provides resistance

to valgus stress on the great toe.to valgus stress on the great toe.

Lateral head of Flexor hallucis Lateral head of Flexor hallucis brevis inserts in the lateral brevis inserts in the lateral sesamoid and oblique and sesamoid and oblique and transverse heads of Adductor transverse heads of Adductor hallucis muscle insert on the hallucis muscle insert on the lateral sesamoid and continues lateral sesamoid and continues to insert in the lateral plantar to insert in the lateral plantar tubercle of proximal phalanx.tubercle of proximal phalanx.

This motor complex resists This motor complex resists varus stress applied to the varus stress applied to the great toe.great toe.

The proximal phalanx and the metatarsal head The proximal phalanx and the metatarsal head are attached by 2 sets of ligamentsare attached by 2 sets of ligaments

i) Medial and Lateral collateral ligamentsi) Medial and Lateral collateral ligaments

ii) Medial and Lateral metatarso-sesamoid ii) Medial and Lateral metatarso-sesamoid ligaments.ligaments.

Sensations to the great toe Sensations to the great toe

i) Dorsal-medial – Superficial Peroneal nervei) Dorsal-medial – Superficial Peroneal nerve

ii) Dorsal-lateral – Deep Peroneal nerveii) Dorsal-lateral – Deep Peroneal nerve

iii) Plantar-medial & Plantar-lateral – by iii) Plantar-medial & Plantar-lateral – by medial & lateral plantar hallucal nerves from medial & lateral plantar hallucal nerves from the Posterior Tibial nervethe Posterior Tibial nerve


Common in sportsCommon in sports

It is mainly due to axial loading of the joint It is mainly due to axial loading of the joint

Hyperdorsiflexion is called ‘TURF TOE’Hyperdorsiflexion is called ‘TURF TOE’

Hyperplantar flexion is called ‘SAND TOE’Hyperplantar flexion is called ‘SAND TOE’

Dorsoplantar translation testDorsoplantar translation test

Dorsoplantar Dorsoplantar Transalation testTransalation test

- Increased translation - Increased translation compared to the compared to the contralateral side denote contralateral side denote significant instability of significant instability of the capsuloligamentous the capsuloligamentous complex.complex.

Classification of Turf toe injuriesClassification of Turf toe injuriesSigns and Signs and symptomssymptoms

PathologyPathology TreatmentTreatment CourseCourse

Grade 1Grade 1 Plantar and Plantar and medial tenderness medial tenderness

Minimal swellingMinimal swelling

No echymosisNo echymosis

Intrasubstance Intrasubstance stretch of stretch of capsular capsular structuresstructures

RestRest

IceIce

CompressionCompression

ElevationElevation

May play with May play with protectionprotection

Grade 2Grade 2 Diffuse Diffuse tendernesstenderness

Mild to moderate Mild to moderate swellingswelling

EchymosisEchymosis

Decreased range Decreased range of motionof motion

Tear of Tear of capsular capsular structuresstructures

Include buddy Include buddy taping with taping with above protocolabove protocol

Upto 2 wks Upto 2 wks loss of activityloss of activity

Grade 3Grade 3Severe difffuse Severe difffuse tendernesstenderness

Marked swelling, Marked swelling, echymosisechymosis

Marked decrease in Marked decrease in range of motionrange of motion

Capsular tear Capsular tear with articular with articular compression compression usually dorsallyusually dorsally

Add immobilization Add immobilization until able to bear until able to bear weight comfortabllyweight comfortablly

Stiff forefoot insertion Stiff forefoot insertion to resist to resist MTPdorsiflexionMTPdorsiflexion

3 – 6 wks of 3 – 6 wks of loss of activityloss of activity

Sesamoid FracturesSesamoid Fractures

Anatomy – Anatomy – as discussed beforeas discussed before

- They function within the joint complex as shock absorbers and They function within the joint complex as shock absorbers and fulcrums in supporting the weight bearing function of the first fulcrums in supporting the weight bearing function of the first toe.toe.

- Their position on either side of the Flexor hallucis longus Their position on either side of the Flexor hallucis longus forms a bony tunnel to protect the tendon.forms a bony tunnel to protect the tendon.

- Medial plantar branch from posterior tibial artery provides – Medial plantar branch from posterior tibial artery provides – vascular supply.vascular supply.


i)i) Fall from heightFall from height

ii) ii) Hyperpronation and Hyperpronation and axial loading as seen axial loading as seen in joint dislocationin joint dislocation

Fracture PatternFracture Pattern

i)i) Transverse fractures – more commonTransverse fractures – more common

ii) ii) Communited and stellate fracturesCommunited and stellate fractures

- - Medial sesamoid is more often injuredMedial sesamoid is more often injured

Partite SesamoidPartite Sesamoid

Occurs due to non union of one or more Occurs due to non union of one or more ossification centres during the formation of a ossification centres during the formation of a sesamoid. sesamoid.

Commonly exhibited by the medial sesamoidCommonly exhibited by the medial sesamoid

Differences between Partite Differences between Partite Sesamoid and fracture of SesamoidSesamoid and fracture of Sesamoid

Partite sesamoidPartite sesamoid

- Smooth sclerotic edges Smooth sclerotic edges

- Sum of the partite sesamoids parts makes a Sum of the partite sesamoids parts makes a sesamoid larger than a normal onesesamoid larger than a normal one

Fracture of Sesamoid Fracture of Sesamoid

Fracture margin is rough and irregularFracture margin is rough and irregular

Minimal separation of the fragments due to tight Minimal separation of the fragments due to tight support of plantar plate unless the plate is tornsupport of plantar plate unless the plate is torn

Sum of the fracture fragments should equal a normal Sum of the fracture fragments should equal a normal sesamoid sizesesamoid size

Fracture Callus apparent on subsequent follow upsFracture Callus apparent on subsequent follow ups

TreatmentTreatment

Stable injury – cast immobilization with a toe plate to Stable injury – cast immobilization with a toe plate to prevent dorsiflexion of the MTP joint and NWB for prevent dorsiflexion of the MTP joint and NWB for 4 – 6 wks.4 – 6 wks.

Prolonged symptoms and failed conservative therapy Prolonged symptoms and failed conservative therapy should be managed with excision of sesamoid or bone should be managed with excision of sesamoid or bone grafting of the ununited defect.grafting of the ununited defect.

Phalangeal FracturesPhalangeal Fractures

Phalangeal fractures are the most common Phalangeal fractures are the most common injury to the forefootinjury to the forefoot

Fractures of the proximal phalanx are common Fractures of the proximal phalanx are common than fractures of the middle and distal phalanx.than fractures of the middle and distal phalanx.


i)i) Direct blow such as heavy object dropped Direct blow such as heavy object dropped onto the foot causes transverse or onto the foot causes transverse or communited fracture. communited fracture.

ii)ii) Injury resulting from axial loading is Injury resulting from axial loading is secondary varus or valgus force result in a secondary varus or valgus force result in a spiral or oblique fracture.spiral or oblique fracture.

TreatmentTreatment

Nondisplaced fractures – Buddy’s strapping Nondisplaced fractures – Buddy’s strapping techniquetechnique

Displaced fractures – close reduction and Displaced fractures – close reduction and immobilization with Buddy techniqueimmobilization with Buddy technique

Operative reduction – Gross instability or persistent Operative reduction – Gross instability or persistent intraarticular discontinuityintraarticular discontinuity

Grossly unstable fractures – reduction and Grossly unstable fractures – reduction and percutaneous k-wires fixation which is percutaneous k-wires fixation which is removed after 4 wks and followed by buddy removed after 4 wks and followed by buddy strapping until asymptomatic and full weight strapping until asymptomatic and full weight bearing.bearing.

Compartment syndrome of the footCompartment syndrome of the foot

Anatomy Anatomy 9 compartments of the foot9 compartments of the foot

Medial CompartmentMedial Compartment

Location : Plantar and medial to 1Location : Plantar and medial to 1stst metatarsal metatarsal

Contents : Abductor hallucis and Flexor Contents : Abductor hallucis and Flexor hallucis brevishallucis brevis

Lateral CompartmentLateral Compartment

Location : Inferolateral surface of the 5Location : Inferolateral surface of the 5 thth metatarsalmetatarsal

Contents : Abductor digiti minimi, Flexor Contents : Abductor digiti minimi, Flexor digiti minimi digiti minimi

Central CompartmentCentral Compartment

Divided into Superficial and Deep Divided into Superficial and Deep compartmentscompartments

- The deep or calcaneal compartment contains The deep or calcaneal compartment contains Quadratus plantae muscle Quadratus plantae muscle

- The superficial compartment contains Flexor The superficial compartment contains Flexor digitorium longus and brevis muscles. digitorium longus and brevis muscles.

Other CompartmentsOther Compartments

Between each of the metatarsals lie the dorsal Between each of the metatarsals lie the dorsal and plantar interosseous muscles which appear and plantar interosseous muscles which appear to lie in a separate compartment defined by to lie in a separate compartment defined by each intermetatarsal space.each intermetatarsal space.

The oblique head of Adductor hallucis lies in a The oblique head of Adductor hallucis lies in a fascial compartment distal and deep to the fascial compartment distal and deep to the quadratus plantae in the plantar aspect of the quadratus plantae in the plantar aspect of the forefoot.forefoot.

TreatmentTreatment

Release of the foot compartments to be done Release of the foot compartments to be done under emergency basis.under emergency basis.

Three incisional approach is the most reliable Three incisional approach is the most reliable way for the release.way for the release.

ApproachApproach

- Two dorsal incisions are placed - Two dorsal incisions are placed

1) medial to the 21) medial to the 2ndnd metatarsal metatarsal shaftshaft

2) lateral to the 42) lateral to the 4thth metatarsal shaft metatarsal shaft

- Blunt dissection is done between - Blunt dissection is done between the interosseous muscles and the interosseous muscles and the fascia to the deep the fascia to the deep compartments.compartments.

- The lateral compartment is reached - The lateral compartment is reached by releasing the fascia atttached to by releasing the fascia atttached to the inferolateral aspect of the 5the inferolateral aspect of the 5thth metatarsal through the lateral metatarsal through the lateral incisionincision

ApproachApproach

The 3The 3rdrd is a medial incision to is a medial incision to access the medial and central access the medial and central compartments.compartments.

The incision is within the The incision is within the arch of the foot along the arch of the foot along the muscle of Abductor hallucis.muscle of Abductor hallucis.

The wounds should be closed The wounds should be closed in a secondary fashion 5 – 7 in a secondary fashion 5 – 7 days later.days later.

THANK YOUTHANK YOU

‘‘There is nothing in a caterpillar that tells There is nothing in a caterpillar that tells you it’s going to be a butterfly’you it’s going to be a butterfly’

-Buckminster Fuller-Buckminster Fuller

FRACTURES AND DISLOCATIONS OF THE MIDFOOT AND FOREFOOT

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