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trauma_foot

the injured foot

introduction

  • foot injuries are common and significant injuries are commonly missed unless actively sort by the treating clinician.
  • delayed diagnosis or misdiagnosis of important injuries can contribute to long term morbidity
  • this is particularly likely in those who have been injured by large forces such as fall from a height, sports injuries, skiing injuries and motor vehicle accidents.
  • common complications include non-union (esp. Jones fracture), avascular necrosis (esp. talar neck), osteoarthritis, osteochondritis (eg. undisplaced talar dome injuries), osteomyelitis (compound injuries or post-ORIF) and mechanical pain syndromes from ligamentous injury.

osteochondroses in the foot

  • Sever's disease - calcaneus
  • Köhler's disease - navicular
  • Frieberg's disease - metatarsal head (usually 2nd or 3rd)

talus fractures

talar neck fractures

  • commonly occurs in car accidents and light aircraft accidents from excessive dorsiflexion with foot on the brake pedal
  • also occurs in falls from a height in crouching position
  • talar neck fractures are associated with avascular necrosis risk (10% with type I, 50% in type II, 85% in type III)

type I injury

  • no displacement
  • Rx padded plaster with toe platform and elevation for 1 week, r/v in fracture clinic for possible non-weight bearing with crutches for 8-12 weeks and reassessment then for union, and avascular necrosis

type II injury

  • subtalar subluxation with proximal part becoming plantar flexed as the distal fragment displaces forwards
  • Rx is usually with ORIF, contact ortho.

type III injury

  • tibia driven between the talar fragments
  • Rx:
    • refer to ortho ASAP
    • consider attempting closed reduction
    • usually needs ORIF

type IV injury

  • rare
  • head of talus dislocated from the navicular in association with a type II or type III injury

talar dome fractures

  • shearing injury may force a piece of the talar dome upper articular surface to detach
  • small fragments may be excised
  • larger fragments may require ORIF
  • most will need 6 weeks in BKPOP

non-articular talar avulsion fractures

  • flakes of talar bone are commonly avulsed during ankle injuries from pull of the ankle ligaments or capsular attachments
  • these require symptomatic Rx only - eg. 2-4 wks in a walking BK plaster

talar body fracture

  • may occur during compression injuries such as fall from a height
  • generally require CT scan and ortho opinion
  • most are managed without surgery but usually require at least 8-10 weeks non-weight bearing and many will have long term pain and restricted function

calcaneal fractures

  • these usually occur following a fall from a height and must be carefully looked for in anyone with such a history.
  • it is commonly bilateral
  • Xray findings can be subtle
    • check Bohler's salient angle - should be ~40deg and is less than this in fractures which flatten the heel profile
  • when in doubt, consider CT scan
  • most patients will require admission

mid-tarsal dislocations

  • the mid-tarsal joint lies between the talus and calcaneum posteriorly, and the navicular and cuboid anteriorly
  • dislocation of the talonavicular portion of the midtarsal joint may accompany subtalar dislocations which may have partly reduced spontaneously
  • dislocation may be associated with fractures, particularly, the navicular
  • Rx is usually with closed reduction +/- K wires for 3-4 weeks, or ORIF

isolated navicular fracture

  • avulsion fractures can usually be Rx with 6 weeks in BKPOP
  • displaced fractures of the body should be urgently reduced to reduce risk of oedema and circulatory impairment, then accurately reduced and fixed surgically

fracture base 5th metatarsal

  • fracture of the base of the 5th MT involving the tarso-metatarsal joint NOT to be confused with a more sinister Jones fracture
  • these are common fractures associated with “ankle sprains” from inversion of the ankle as a result of bony avulsion due to stress on peroneus brevis tendon which inserts at this point
  • these fractures are easily missed unless looked for.
  • in children, take care not to misdiagnose the normal physeal line as being a fracture
    • fractures are usually transverse whilst the apophyseal line (growth plate) is more longitudinal
  • whilst many can be managed with crutches and tubigrip, healing may be quicker with a cast

Jones fracture

  • fracture of the proximal diaphysis of the fifth metatarsal involving the intermetatarsal joint NOT the tarso-metatarsal joint
  • this is NOT caused by inversion injuries but commonly occurs in athletes
  • commonly results in non-union due to the poor blood supply to this bone and thus can result in chronic pain
  • BKPOP for 6-8 weeks will heal 75%
  • athletes or those at risk should be referred for possible ORIF

LisFranc fracture dislocation tarso-metatarsal joints

  • usually follow large forces such as fall from a height, sports injuries or car accidents.
  • may occur when a car wheel runs over forefoot with heel on the gutter edge
  • Xray usually will show the injury but may require weight bearing views to demonstrate collapse of the normal arch, or CT scan.
  • most need surgical repair and there is a high risk of long term sequelae.

metatarsal fractures

  • often result from crush injuries
  • spiral shaft injuries may result from forced inversion or eversion of the forefoot
  • children often fracture the bases or necks of 2nd - 4th MT's and these can usually be managed in BKPOP
  • BEWARE LisFranc and Jones fractures (see above)

metatarsalgia

DDx

  • stress fracture - esp. 2nd MT neck or shaft (“march fracture”)
  • Morton's neuroma - most commonly occurs in the webspace between the 3rd and 4th toes
  • sesamoiditis
  • fracture sesamoid of the hallux - sometimes may require operative Rx1)
  • MTP joint arthritis - esp. gout, rheumatoid arthritis and psoriatic arthritis
  • bursitis
  • Freiberg's disease - osteochondritis of a metatarsal head (usually the 2nd or 3rd) in adolescents

fracture toe

  • most fractures can be managed by buddy taping toe to next toe with gauze between the toes
  • significantly angulated or displaced fractures may need closed reduction under a digital block
  • compound fractures generally require referral for Mx as usual for compiund fractures:
    • wound irrigation and closure
    • tetanus prophylaxis
    • iv antibiotics
trauma_foot.txt · Last modified: 2016/06/13 08:37 by gary1