FOOT FRACTURE.pptx

Foot

1. FOOT FRACTURE PRESENTER:DR.BALARAJU 1ST YR PG ORTHO

2. Foot and its bones divided into following three Hindfoot -calcaneus and talus Midfoot-cuboid,navicular and cuneiforms Forefoot-metatarsals and phalanges

3. HINDFOOT

4. CALCANEUS FRACTURE EPIDEMIOLOGY CALCANEUS FRACTURE ACCOUNTS FOR APPROXIMATELY 1% TO 2% OF ALL FRACTURES MOST FREQUENTLY FRACTURED TARSAL BONE ANNUAL INCIDENCE -11.5 PER 100000 PEOPLE M:F IS 2.4:1 PEAK INCIDENCE IN MALES AGED 20 TO 29 YS Rare in childrens (less than 2%) involving older children and adolescents(>9yr) In childrens most are extra-articular, involving the apophysis or tuberosity

5. Anatomy anatomy of calcaneus is complex The articular surface contains 3 facets that articulate with the talus The posterior facet is the largest and constitutes the major weight bearing surface. The middle facet is located anteromedially on the sustentaculum tali.

6. B/W the middle and Posterior facets lies the interosseoussulcus which,with the talar sulcus forms the sinus tarsi The sustentaculum tali supports the neck of talus medially, it is attached to the talus by the interosseous talocalcaneal ligament and deltoid ligaments and contains the middle articular facet on its superior aspect

7. Radiographic evaluation Lateral view of hindfoot AP view Harris axial view; this is taken with the foot in dorsiflexion and the beam angled at 45 degrees Mortise view CT scan

8. The B ohler angle : It is composed of a line drawn from the highest point of the anterior process of calcaneus to the highest point of posterior facet. Normally angle is 20 to 40 degrees;decrease in angle indicates calcaneus fracture

9. The G issane angle :Formed by two strong cortical struts extending laterally,one along the lateral margin of the posterior facet and other extending anterior to the beak of the calcaneus:angle between 105 to 135 degree

10. MECHANISM OF INJURY Axial loading : - falls from a height Motor vehicle accidents Twistingforces Associated with extra articular calcaneus fracture

11. CLASSIFICATION FOR CALCANEUS FRACTURES Calcaneus fractures are extra articular fractures and intra articular fracture EXTRA ARTICULAR FRACTURES : These do not involve the posterior facet, these are Anterior process fractures Medial process fractures Sustentacular fractures Body fractures not involving the subtalar articulation Tuberosity fractures of the posterior calcaneus

12. INTRA ARTICULAR FRACTURES CLASSIFICATION Essex- Lopresti classification Primary Fracture L ine : force of talus splits the calcaneus obliquely through the posterior facet Anteromedial fragment is rarely comminuted and remains attached to talus by the deltoid and interosseous talocalcaneal ligaments The posterolateral fragment usually displaces superolaterally with variable comminution

13. Secondary Fracture L ine : With continued compressive forces,there is additional comminution ,creating a free lateral piece of posterior facet separate from the tuberosity fragment Tongue-type fracture: A secondary fracture line appears beneath the posterior facet and exits posteriorly through the tuberosity. Joint depression fracture : a secondary fracture line exits just behind the posterior facet

14. Sanders Classification This is based on CT scan This classification is based on the number and location of articular fragments, it is based on the coronal image which shows the widest surface of posterior facet of the talus The posterior facet of the calcaneus is divided into 3 fracture lines. (A, B , AND C corresponding to lateral , middle, d medial fracture lines on the coronal image)

15. Thus there can be a 4 potential pieces: lateral,central,medial and sustentaculum tali Type 1 ; all nondisplaced fractures regardless of the number of fracture lines Type 2 : two part fractures of the posterior facet ; subtypes 2A,2B,2C, based on the location of the primary fracture line Type 3: 3 parts fractures with a centrally depressed fragment; subtypes 3AB,3AC,3BC Type 4 : 4 part articular fractures: highly comminuted

16. Schmidt and weiner classification in childrens

17. Management Nonoperative Indications: Nondisplaced r minimally displaced extra-articular fractures Nondisplaced intra-articular fractures Anterior process fractures with less 25% involvement of the CC articulation Pvd , dm and massive prolong edema Other medical comarbidities

18. Nonoperative T reatment C onsists of a supportive splint to allow dissipation of the initial fracture hematoma . Ankle joint range of motion exercises are initiated and non weight bearing restrictions are maintained for 10 to 12 wks.

19. Operative Treatment Indications: Displaced intra-articular fractures involving the posterior facet Anterior process of the calcaneus fractures with >25% involvement of the calcaneal-cuboid articulation Open fracture of calcaneus Fracture-dislocation of the calcaneus Gastrocnemius-soleus complex is incompetent

20. Percutaneous or Minimally Invasive Fixation of Displaced TongueType , Calcaneal Tuberosity, or Beak Fractures Open Reduction and Internal Fixation of Anterior Process Fractures Posterior facet reduced and stabilized with lag screws into sustentaculum tali . Thin plate placed laterally and is used as a buttress.

21. POSTOP MANAGEMENT Close clinical follow-up is necessary to ensure soft tissues remain in good condition. The leg is kept elevated and iced as needed. patient can be placed in a well-padded short leg cast with the foot and ankle in slight plantarflexion.6 weeks,show minimal fracture displacement with acceptable alignment, the patient can be transitioned to a CAM boot with or without a heel lift and can begin gentle ROM ankle exercises.

22. Complications Hardware prominence and pain Posttraumatic subtalar arthritis, CC arthritis Wound dehiscence, superficial and deep infection, osteomyelitis Calcaneal malunion Sural nerve injury, painful neuroma

23. TALUS FRACTURE

24. ANATOMY Medially and laterally, the articular cartilage extends plantar to articulate with the medial and Lateral malleoli, respectively, The inferior surface of the body forms the articulation with the posterior facet of the calcaneus The vascular supply to the talus consists of: ■ Arteries to the sinus tarsi ( peroneal and dorsalis pedis arteries) ■ An artery of the tarsal canal (posterior tibial artery) ■ The deltoid artery (posterior tibial artery), which supplies the medial body ■ Capsular and ligamentous vessels and intraosseous anastomoses

25. EPIDEMIOLOGY These are second in frequency among all tarsal fractures. ■ The incidence of fractures of the talus ranges from 0.1% to 0.85% of all fractures and 5% to 7% of foot injuries. ■ Approximately 14% to 26% of talar neck fractures have associated fracture of the medial malleolus . ■ Lateral process of the talus fractures are frequently seen in snowboarding injuries and account for 15 % of all ankle injuries. ■ Fractures of the talar head are rare with an incidence of 3% to 5% of all fractures of the talus

26. MECHANISM OF INJURY A motor vehicle accidents A fall from a height with a component of hyperdorsiflexion of the ankle. The talar neck fractures as it impacts the anterior margin of the tibia Aviator’s A stragalus : This historical term refers to the rudder bar of a crashing airplane impacting the plantar aspect of the foot, resulting in a talar neck fracture.

27. Clinical presentation Ankle pain Swelling Tenderness to palpation of talus and subtalarjoint

28. RADIOGRAPHIC EVALUATION Ap,lateral and oblique views ■ Canale view: This provides an optimum view of the talar neck. Taken with the ankle in maximum equinus , the foot is placed on a cassette, pronated 15 degrees, and the radiographic source is directed cephalad 15 degrees from the vertical . This view was described for evaluation of posttraumatic deformity. CT ,MRI and technetium bone scan

29. CLASSIFICATION Anatomic Lateral process fractures Posterior process fracture Talar head fractures Talar body fractures Talar neck fractures

30. TYPE 1: Nondisplaced TYPE 2: Associated subtalar subluxation or dislocation TYPE 3: Associated subtalar and ankle dislocation TYPE 4: Type 3 plus associated talonavicular subluxation or dislocation HAWKINS CLASSIFICATION OF TALAR NECK FRACTURES

31. TREATMENT Nondisplaced Fracture (Hawkins Type 1) Short leg cast or boot for 8 to 12 weeks Non weight bearing for 6 weeks until clinical and radiographic evidence of fracture healing is present Displaced Fractures (Hawkins Types 2 to 4) Immediate closed reduction indicated Early ORIF is indicated for all open or irredicible fractures If anatomic reduction is obtained and confirmed by CT scan,the pt can be placed in a short leg splint and fractures fixation may be delayed INTERNAL FIXATION: Two interfragmentary lag screws or headless screws may be placed perpendicular to the fracture line

32. Areas of significant comminuation and bone loss should be grafted Mini fragment plates have been used laterally more recently in cases of significant comminuation to avoid shortening of the neck A short leg cast or removable boot should be placed postoperatively for 8 to 12 wks and pt should be kept in non weight bearing Nondisplaced or minimally displaced talar body fractures are treated by shortleg cast Displaced talar body fractures treated by ORIF Less than 2cm displaced lateral process fractures treated by shortleg cast for 6 wks and be non weight bearing for 4 wks

33. More than 2cm displaced fractures treaten by ORIF with lag screws Comminuted fractures: Nonreconstructable fragments are excised Nondisplaced or minimally displaced posterior process fractures managed by shortleg cast for 6wks n non wt bearing for 4wks Displaced posterior process fractures managed by ORIF

34. COMPLICATIONS Osteonecrosis Posttramatic arthritis Delayed union and nonunion Infections Malunion Skin slough Interposition of long flexor tendons Foot compartment syndrome

35. SUBTALAR JOINT DISLOCATION It most commonly occurs in young men Inversion of the foot results in a medial subtalar dislocation,whereas evesion produces a lateral subtalar dislocation Up to 85% of dislocations are medial All subtalar dislocations require gentle reduction Reduction involves suffiecient analgesia with knee flexion and longitudinal foot traction Open reduction performed through a longitudinal anteromedial approach for medial dislocation and sustentaculum tali approach for lateral dislocations

36. MIDFOOT FRACTURE

37. Epidemiology Midfoot injuries relatively rare Incidence of midfoot fractures is 3.6 per 1,00,000 per yr Cuboid is most commonly fractured bone followed by navicular and cuneiform M ale:female =1:1.2

38. Anatomy The midfoot is the section of the foot distal to chopart joint line and proximal to lisfranc joint line Five bones constitute in midfoot . Navicular,cuboid and 3 cuneiforms The midtarsal joint consists of the calcaneocuboid and talonavicular joints, which act in concert with subtalar joint during inversion and eversion of the foot Ligamentous attachments include the plantar calcaneonavicular ligament,bifurcate ligament,dorsal talonavicular ligament,dorsal calcaneocuboid ligament,dorsal cuboideonavicular ligament and long plantar ligament

39. MOI High E nergy T rauma - motor vehicle accidents - Fall or jump from a height Low E nergy T rauma - sprain during athletic or dance activities C/ f: Swelling and tenderness on the dorsum of the midfoot to nonambulatory status with significant pain, gross swelling,ecchymosis , and variable deformity Plantar ecchymosis is usually indicative of midfoot injury

40. Radiographic Evaluation AP,Lateral and oblique views foot should be obtained CT helpful in fracture dislocation injuries with articular comminution MRI for ligamentous injuries

41. CLASSIFICATION OF MIDFOOT INJURIES Medial stress injury: Inversion injury occurs with adduction of the midfoot on the hindfoot . Flake fractures of the dorsal margin of the talus or navicular and of the lateral margin of the calcaneus or the cuboid may indicate a sprain

42. Longitudinal stress injury: Longitudinal forces pass between the cuneiforms and fracture the navicular typically in a vertical pattern

43. Lateral stress injury Nutcracker fracture ; this is the fracture of the cuboid as the forefoot driven laterally, crushing the cuboid between the calcaneus and the 4th and 5th metatarsal bases Most commonly this is an avulsion fracture of the navicular with a comminuted compression fracture of the cuboid

44. Plantar stress injury: Forces directed at the plantar region may result in sprains to the midtarsal fractures of the navicular,talus , or anterior process of the calcaneus

45. TREATMENT Nonoperative : Sprains: nonrigid dressings are used with protected weight bearing for 4 to 6 wks ,prognosis is excellent For severe sprains , midfoot immobilization may be indicated Nondisplaced fractures may be treated with a short leg cast or brase with initial non weight bearing for 6 wks

46. Operative Displaced fracture patterns require ORIF(K-WIRES) and external fixation Bone grafting of the cuboid may be necessary following reduction of lateral stress injuries Severe crush injuries with extensive comminution may require arthrodesis to restore the longitudinal arch of the foot

47. Navicular B one A natomy N avicular is the keystone of the medial longitudinal arch of the foot. ■ It is wider on its dorsal and medial aspect than on its plantar and lateral aspect. ■ The medial prominence known as the navicular tuberosity provides the attachment point for the posterior tibialis on its medial inferior surface.

48. Sangeorzan Classification of N avicular B one T he most commonly used classification of navicular fractures is composed of three basic types with a subclassification for body fractures Avulsion-type fracture can involve either the talonavicular or naviculocuneiform ligaments. Tuberosity fractures are usually traction-type injuries with disruption of the tibialis posterior insertion without joint surface disruption. Type I body fracture splits the navicular into dorsal and plantar segments. Type II body fractures cleave into medial and lateral segments. The location of the split usually follows either of the two intercuneiform joint lines. Stress fractures can usually be included in this group. Type III body fractures are distinguished by comminution of the fragments and significant displacement of the medial and lateral poles .

49. Treatment For N avicular B one F racture Nonoperative Nondisplaced fractures of the navicular should be treated in a short leg cast or fracture brace with restricted weight bearing for 6 to 8 weeks. Repeat radiographs should be obtained at 10 to 14 days after the initial injury to confirm the absence of bony or soft tissue instability. If instability appears or other injuries become apparent, appropriate surgical intervention should be considered. Operative K wire fixation Bone graft Postop management: Cast with non weight bearing for 12wks

50. LISFRANC INJURY(TARSOMETATARSAL JOINT INJURY) Rare, mostly seen in poly-traumatized pt’s . MOI : 3 most common mechanism include Torsion : seen in motor vehicle accidents and horse rider Axial loading: seen in jumping and dancing Crushing mechanism: industrial type injuries C/F: Pain Swelling Tenderness Plantar ecchymosis is pathognomonic feature for lisfranc injury

51. Radiographic Evaluation AP, LATERAL AND OBLIQUE FIMLS ARE DIAGNOSTIC THE MEDEAL BORDER OF THE 2ND METATARSALSHOULD BE COLINEAR WITH THE MEDIAL BORDER OF THE MIDDLE CUNEIFORM ON THE AP VIEW

52. The medial border of the 4th metatarsal should be colinear with the medial border of the cuboid on oblique view Dorsal displacement of the metatarsals on the lateral view is indicative of ligamentous compromise MRI and CT scan also useful for suspected lisfranc injuries

53. QUENU AND KUSS Classification of lisfranc injuries Based on extent and pattern of injury Homolateral : all five metatarsals displaced in the same direction Isolated: one or two metatarsals displaced from the others Divergent: displacement of the metatarsals in both the sagittal and coronal planes

54. MYERSON CLASSIFICATION Commonly observed patterns of injury with regard to treatment Total incongruity:lateral and dorsoplantar Partial incongruity:medial and lateral Divergent:partial and total

55. Treatment Nonoperative Short leg cast for pt with nondisplaced ligamentous injuries with or without small Plantar avulsion fractures of the metatarsal or tarsal bones Pt kept non weight bearing to bear weight as comfort allows with crutches and is permitted

56. Operative This should be considered when displacement of the tarsometatarsal joint is >2mm The most common approach is using two longitudinal incisions First one is centered over the first /second inermetatarsal space 2nd one at 4th metatarsal Once reductionis accomplished, screw fixation is advocated for the medial column K wire fixation is acceptable

57. Postoperative management: The foot is immobilized in a non weight bearing cast or boot for 6 to 8wks Lateral column stabilization can be removed at 6 to 12 wks Medial fixation should not be removed for 4 to 6 months Some advocate leaving screws indefinitely unless symptomatic

58. Complications: Post traumatic arthritis Compartment syndrome Infection Complex regional pain syndrome Neurovascular injury

59. FOREFOOT

60. FOREFOOT FRACTURES The forefoot serves two purposes during gait It provides a broad plantar surface for load sharing The forefoot is mobile in the sagittal plane. This helps to the forefoot to alter the position of the individual metatarsal heads to accommodate uneven grounds

61. EPIDEMIOLOGY Most common injuries Incidence is higher in forefoot injuries

62. MOI Direct :this is mc when a heavy object is dropped on the forefoot Avulsion Stress fracture : improper running usually gives rise to the more insidious stress fracture Torsion

63. C/F: Pain Swelling and tenderness over the site of fracture Neurovascular evaluation is important as well as assessment of soft injury

64. RADIOGRAPHIC EVALUATION AP,Lateral and oblique views of the forefoot should be obtained Occasionally , a tangential view of the sesamoids is necessary to visualize a small osteochondral or avulsion fracture Technetium bone scanning or MRI may be used to identify stress fractures

65. TREATMENT FOR FOREFOOT FRACTURE Nonoperative : Rest,ice,compression and elevation and nonsteroidal anti-inflammatory medication are used Splinting: soft padding combined with a short leg walking cast for 4 to 6 wks Rigid or stiff-soled shoe Buddy taping for phalanges fractures

66. Operative Small osteochondral fractures may be excised Larger fragments require reduction with k wires,compression screws or headless screws

67. Complications: Posttraumatic osteoarthritis Recurrent dislocation at MTP Joints, this is uncommon

68. Named F ractures In F oot Shepherd’s fracture : fracture of the lateral tubercle of the posterior process of the talus March fracture :it occurs in distal 3rd of one of the metatarsals(2nd and 3rd commonly) d/t recurrent stress

69. Chopart`s fracture-dislocation: Foot dislocation through talonavicular and calcaneocuboid joints Lisfranc fracture fracture dislocation of midfoot from tarsometatarsal joints Jones fracture: distal to tuberosity of the base of 5 th metatarsal fracture(zone2) Pseudo jones fracture : Cancellous tuberosity fracture(zone1) of the base of 5 th metatarsal

70. Amputation surgeries for foot Syme’s amputation Choparts amputation Lisfranc’s amputation Transmetatarsal amputation Metatarsal phalangeal disarticulation Toe amptation or disarticulation

71. References : Rockwood Campbell Koval J.Maheshwari