trauma_foot
Table of Contents
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: 2020/01/28 11:21 by 127.0.0.1