fractures and dislocations of the midfoot and forefoot

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FRACTURES ANDFRACTURES AND DISLOCATIONS OF THEDISLOCATIONS OF THE MIDFOOT ANDMIDFOOT AND FOREFOOT FOREFOOTDR. KRISHNA MADHUKAR .DDR. KRISHNA MADHUKAR .D Anatomical divisions of the foot Anatomical divisions of the footNavicular Fractures Navicular FracturesAnatomyAnatomy - - Keystone oI the medial longitudinal arch oI the Ioot Keystone oI the medial longitudinal arch oI the Ioot- - Medial ProminenceMedial Prominencenavicular tuberosity provides insertion tonavicular tuberosity provides insertion to the Tibialis posterior. the Tibialis posterior.- - Proximal articular surIace articulates with the Talus Proximal articular surIace articulates with the Talus- - Distal articular surIace articulates with the 3 cuneiIorm bones. Distal articular surIace articulates with the 3 cuneiIorm bones.- - Laterally articulates with the cuboid. Laterally articulates with the cuboid.- - Spring and superIicial deltoid ligaments provide strongSpring and superIicial deltoid ligaments provide strong support to plantar and medial aspect oI talonavicular ioint. support to plantar and medial aspect oI talonavicular ioint.- - Calcaneonavicular ligament supports lateral and dorsal aspectsCalcaneonavicular ligament supports lateral and dorsal aspects oI talonavicular ioint. oI talonavicular ioint.- - Blood supplyBlood supplyDorsalis pedis and medial plantar arteries byDorsalis pedis and medial plantar arteries by radial distribution . radial distribution .- - PerIusion is abundant along the periphery but is avascularPerIusion is abundant along the periphery but is avascular centrally. centrally.Sangeorzan classification Sangeorzan classificationA) A) Avulsion type Iracture Avulsion type IractureCan involve eitherCan involve either talonavicular ortalonavicular or naviculocuneiIormnaviculocuneiIorm ligaments ligamentsB) Tuberosity IracturesB) Tuberosity Iractures Traction type iniuriesTraction type iniuries with disruption oIwith disruption oI Tibialis posteriorTibialis posterior insertion without iointinsertion without ioint surIace disruption surIace disruptionC) C)TYPE 1TYPE 1 Body Iracture splits theBody Iracture splits the navicular into dorsalnavicular into dorsal and plantar segments. and plantar segments.C) C)TYPE 2 TYPE 2Body Iracture spilts theBody Iracture spilts the navicular into medialnavicular into medial and lateral segments and lateral segmentsC)C) TYPE 3 TYPE 3Body IractureBody Iracture distinguished bydistinguished by communition oI thecommunition oI the Iragments andIragments and signiIicant displacementsigniIicant displacement oI the medial and lateraloI the medial and lateral parts. parts.TreatmentTreatment Two criteria important in obtainingTwo criteria important in obtaining satisIactory outcome. satisIactory outcome.a) a) Maintanence and restoration oI the medial column length. Maintanence and restoration oI the medial column length.b) b) Articular congruity oI the talonavicular ioint. Articular congruity oI the talonavicular ioint.Closed management of NavicularClosed management of Navicular fracturesfractures Indications Indications- - Less than 2mm displacement oI the talonavicular ioint surIace. Less than 2mm displacement oI the talonavicular ioint surIace.- - No evidence oI mid Ioot instability. No evidence oI mid Ioot instability.- - No loss oI bony length. No loss oI bony length.Treatment by closed management. Treatment by closed management.Short leg NWB cast Ior 6Short leg NWB cast Ior 68 wks. 8 wks.Recheck stability with stress views aIter 10 days IromRecheck stability with stress views aIter 10 days Irom iniury iniuryProgressive weight bearing in protective brace untillProgressive weight bearing in protective brace untill asymptomatic asymptomatic..Operative management of NavicularOperative management of Navicular Fractures. Fractures. Priority oI Iixation Priority oI Iixation- - Maintain position oI the Navicular in the Ioot Maintain position oI the Navicular in the Ioot- - Preserve Talonavicular congruity. Preserve Talonavicular congruity.- - Restore attachment oI the Posterior tibialis tendon Restore attachment oI the Posterior tibialis tendon- - Preserve naviculocuniIorm articulations. Preserve naviculocuniIorm articulations.Fixation Fixation1) 1) Stabilization oIStabilization oI individual Iragmentsindividual Iragments accomplished by 2.7, 3.5,accomplished by 2.7, 3.5, 4.0 mm SCREW4.0 mm SCREW FIXATION FIXATION2) Restoration oI medial2) Restoration oI medial column length incolumn length in communited Iracturescommunited Iractures by external Iixation orby external Iixation or internal plating tointernal plating to protect the reductionprotect the reduction and prevent excess iointand prevent excess ioint motion until the Iracturemotion until the Iracture stabitizes. stabitizes.3) Liberal use oI3) Liberal use oI cancellous orcancellous or corticocancellous graItcorticocancellous graIt to Iill structural deIects. to Iill structural deIects.4) II greater than 40 oI Talonavicular ioint4) II greater than 40 oI Talonavicular ioint articular surIace cannot be reconstructed anarticular surIace cannot be reconstructed an acute Talonavicular Iusion should be done toacute Talonavicular Iusion should be done to preserve Ioot alignment. preserve Ioot alignment.!ost operative care !ost operative care Below knee cast with Ioot in plantigradeBelow knee cast with Ioot in plantigrade position. position. Non Weight bearing Ior 8 wks Non Weight bearing Ior 8 wks Progressive weight bearing as tolerated at 8Progressive weight bearing as tolerated at 8 wks. wks. Supportive brace until pain Iree Iull weightSupportive brace until pain Iree Iull weight bearing is achieved. bearing is achieved.Complications Complications Non union. Non union. Arthritic degeneration. Arthritic degeneration. Late instability. Late instability. Bony resorption with loss oI normal IootBony resorption with loss oI normal Ioot alignment. alignment. Collapse and avascular necrosis. Collapse and avascular necrosis.NAVICULAR DISLOCATION NAVICULAR DISLOCATION Dislocation or subluxation oI the navicular isDislocation or subluxation oI the navicular is rare. rare. Dislocates medial and plantar to its normalDislocates medial and plantar to its normal position in neuropathic instabilty position in neuropathic instabilty Dislocates dorsal in acute traumaDislocates dorsal in acute trauma Trauma mechanism Trauma mechanism Initial hyperplantar Ilexion oI the IoreIoot with subsequentInitial hyperplantar Ilexion oI the IoreIoot with subsequent axial loading axial loading Ligamentous disruptions in dorsal and plantarLigamentous disruptions in dorsal and plantar NaviculocuneiIorm ligaments. NaviculocuneiIorm ligaments. Dislocation in neuropathic Ioot is due to motor pull withDislocation in neuropathic Ioot is due to motor pull with ligamentous Iailure. ligamentous Iailure. Tibialis posterior pulls the navicular plantar and medial to theTibialis posterior pulls the navicular plantar and medial to the Ioot. Ioot.Treatment for dislocation Treatment for dislocation Similar to that advocated in IractureSimilar to that advocated in Iracture management. management.CUBOID FRACTURES CUBOID FRACTURESApplied Anatomy. Applied Anatomy.- - Part oI lateral column support oI the Ioot. Part oI lateral column support oI the Ioot.- - Proximal saddle shaped articulation with the Calcaneum acts as a stress valve IorProximal saddle shaped articulation with the Calcaneum acts as a stress valve Ior imperIectly matched movements oI the Talonavicular and subtalar ioints. imperIectly matched movements oI the Talonavicular and subtalar ioints.- - Distally articulates with 4 Distally articulates with 4th thand 5 and 5th thmetatarsals. metatarsals.- - Variable articulations with navicular and lateral cuneiIorm on the dorsomedialVariable articulations with navicular and lateral cuneiIorm on the dorsomedial aspect oI cuboid. aspect oI cuboid.- - Peroneus longus courses along the lateral and plantar surIaces oI the Cuboid on itsPeroneus longus courses along the lateral and plantar surIaces oI the Cuboid on its way to the base oI the 1 way to the base oI the 1st stmetatarsal.metatarsal. Mechanism of injury Mechanism of injuryForced plantar IlexionForced plantar Ilexion and abduction causing aand abduction causing a compressive load alongcompressive load along the long axis oI thethe long axis oI the cuboid. cuboid. NUT CRACKER FRACTURE` NUT CRACKER FRACTURE`Closed management of CuboidClosed management of Cuboid fractures fractures INDICATIONS INDICATIONS- - Less than 2mm displacement oI theLess than 2mm displacement oI the Calcaneocuboid or Cuboid metatarsal iointCalcaneocuboid or Cuboid metatarsal ioint surIace. surIace.- - No evidence oI Cuboid subluxationNo evidence oI Cuboid subluxation - - No loss oIbony length.No loss oIbony length. TREATMENT TREATMENT- - Below knee cast with NWB Ior 6 Below knee cast with NWB Ior 6- -8 wks. 8 wks.- - Recheck stability with stress views at 10 days oIRecheck stability with stress views at 10 days oI iniury. iniury.- - Progressive weight bearing in protective brace untilProgressive weight bearing in protective brace until asymptomatic aIter 8 wks. asymptomatic aIter 8 wks.Operative Treatment Operative TreatmentOALS OALS- - Restoration oI the lateral column lengthand plantarRestoration oI the lateral column lengthand plantar support oI the mid Ioot. support oI the mid Ioot.- - Mobility oI the Tarsometatarsal ioints. Mobility oI the Tarsometatarsal ioints.- - Articular integrity oI Calcaneocuboid ioint. Articular integrity oI Calcaneocuboid ioint.2.7 and 3.5mm cortical2.7 and 3.5mm cortical lag screws are usedlag screws are used across the Iracture planeacross the Iracture plane in simple longitudinalin simple longitudinal Iractures.Iractures. Small external IixationSmall external Iixation to restore lateral columnto restore lateral column length in displaced andlength in displaced and compressed Iractures. compressed Iractures.- - 2 pins distal calcaneum 2 pins distal calcaneum- - 1 pin each in the 4 1 pin each in the 4th thandand 55th thmetatarsal bases. metatarsal bases.!ost Operative care !ost Operative care Below knee cast in neutral and plantigradeBelow knee cast in neutral and plantigrade positionIor 6 wks. positionIor 6 wks. Reduction pins and external Iixator areReduction pins and external Iixator are removed at 6 wks. removed at 6 wks. AIter 6wksAIter 6wksNWB, removable splint, selINWB, removable splint, selI directed ROM exercises through ankle anddirected ROM exercises through ankle and subtalar ioints. subtalar ioints. Wt bearing aIter 10 wks. Wt bearing aIter 10 wks.CUBOID DISLOCATION CUBOID DISLOCATION Isolated subluxation or dislocation is rare. Isolated subluxation or dislocation is rare. PainIul subluxation termed as CUBOIDPainIul subluxation termed as CUBOID SYNDROME` has been reported in 9 oISYNDROME` has been reported in 9 oI high perIormance atheletes and 17 oIhigh perIormance atheletes and 17 oI proIessional ballet dancers proIessional ballet dancersSymptoms of Cuboid SyndromeSymptoms of Cuboid Syndrome Lateral Ioot pain radiating to anterior ankle,Lateral Ioot pain radiating to anterior ankle, Iourth ray or plantar aspect oI the mid Ioot. Iourth ray or plantar aspect oI the mid Ioot. Weakness in IoreIoot push oII. Weakness in IoreIoot push oII.Findings in Cuboid Syndrome Findings in Cuboid Syndrome Reduction in dorsolateral to plantar medialReduction in dorsolateral to plantar medial mobility through Calcaneocuboid ioint. mobility through Calcaneocuboid ioint. Peroneus longus spasm. Peroneus longus spasm. Pain with pressure applied to the plantar aspectPain with pressure applied to the plantar aspect oI the cuboid. oI the cuboid.The position oIThe position oI dislocated cuboid isdislocated cuboid is always plantar andalways plantar and medial. medial.Treatment Treatment No rotation or subluxationNo rotation or subluxationmanaged closed. managed closed. Open reduction and internal Iixation with kOpen reduction and internal Iixation with k wires or screws trough the lateral cuneiIormwires or screws trough the lateral cuneiIorm into the cuboid is advised. into the cuboid is advised. KKwires are removed aIter 4 wks with NWB. wires are removed aIter 4 wks with NWB.IN1URY TO THE OS !ERONEUM IN1URY TO THE OS !ERONEUMOs Peroneum is a sesamoid lying within theOs Peroneum is a sesamoid lying within the substance oI the Peroneus longus tendon. substance oI the Peroneus longus tendon.It is Iound at the level oI the Cuboid tunnel where theIt is Iound at the level oI the Cuboid tunnel where the Peroneus longus tendon passes under the Cuboid or atPeroneus longus tendon passes under the Cuboid or at the level oI the Calcaneocuboid ioint. the level oI the Calcaneocuboid ioint.Present in 5Present in 514 oI the population. 14 oI the population.Mode of injury Mode of injuryIniury to this bone canIniury to this bone can be caused by directbe caused by direct blow or supination andblow or supination and plantar Ilexion Iorcesplantar Ilexion Iorces that cause tensile loadsthat cause tensile loads across the bone.across the bone. Treatment TreatmentNWB cast Ior minimal oI 6wks. NWB cast Ior minimal oI 6wks.Progressive weight bearing in a cast untilProgressive weight bearing in a cast until asymptomatic. asymptomatic.II painIul Iibrous union occurs excision oI the boneII painIul Iibrous union occurs excision oI the bone ligaments to be done. ligaments to be done.Cuneiform Injuries Cuneiform Injuries Anatomy Anatomy- - Three cuneiIorms are present in the middle oI the medialThree cuneiIorms are present in the middle oI the medial column oI the Ioot and support the medial longitudinal arch. column oI the Ioot and support the medial longitudinal arch.- - All are wedge shaped along the axial axis. All are wedge shaped along the axial axis.- - Medial cuneiIorm has plantar base and dorsal crest where asMedial cuneiIorm has plantar base and dorsal crest where as middle and lateral cuneiIorms have dorsal bases and plantarmiddle and lateral cuneiIorms have dorsal bases and plantar crests. crests.- - Proximally each cuneiIorm articulates with 1/3 oI theProximally each cuneiIorm articulates with 1/3 oI the distal navicular and distally articulate with thedistal navicular and distally articulate with the respective metatarsals. respective metatarsals.- - Between each oI the 2 cuneiIorm pairs there are 3Between each oI the 2 cuneiIorm pairs there are 3 distinct connecting ligaments. distinct connecting ligaments.Mechanism of injury Mechanism of injuryCuneiIorm Iractures areCuneiIorm Iractures are due to indirect axialdue to indirect axial loading oI the bone. loading oI the bone.Commonly seen in coniunction with TarsometatarsalCommonly seen in coniunction with Tarsometatarsal iniuries. iniuries.Fracture or Iracture dislocation oI these bones signiIyFracture or Iracture dislocation oI these bones signiIy severe ligamentous iniury oI the mid Ioot. severe ligamentous iniury oI the mid Ioot.Medial cuneiIorm instability usally occurs withMedial cuneiIorm instability usally occurs with minimal energy. minimal energy.A noticeable increase inA noticeable increase in the size oI the Iirst webthe size oI the Iirst web space is reported inspace is reported in isolated medialisolated medial cuneiIorm iniury. cuneiIorm iniury.APSIN` APSIN`Treatment Treatment Closed Management Closed ManagementIndications Indications. No evidence oI instability with wt bearing or stress x . No evidence oI instability with wt bearing or stress x- -rays. rays.. No loss oI bony length. . No loss oI bony length.Treatment Treatment. NWB below knee cast Ior 6 . NWB below knee cast Ior 6- -8 wks. 8 wks.. Progressive weight bearing in protective brace until. Progressive weight bearing in protective brace until asymptomatic asymptomaticSurgical management Surgical managementNon anatomic reductionNon anatomic reduction or continued instabilityor continued instability should be treated withshould be treated with open reduction and pinopen reduction and pin and screw Iixation intoand screw Iixation into adiacent stableadiacent stable structures. structures. Use oI corticocancellous graIts Ior anyUse oI corticocancellous graIts Ior any evidence oIbony crush. evidence oIbony crush. Instability oI medial cuneiIorm requiresInstability oI medial cuneiIorm requires internal Iixation even iI anatomic reduction isinternal Iixation even iI anatomic reduction is obtained through traction. obtained through traction. Unstable articulations require intercuneiIormUnstable articulations require intercuneiIorm and naviculocuneiIorm Iusion.and naviculocuneiIorm Iusion. Lisfranc`s 1oint Injuries Lisfranc`s 1oint Injuries Any bony or ligamentous iniury involving theAny bony or ligamentous iniury involving the tarsometatarsal ioint complex. tarsometatarsal ioint complex. Named aIter the Napoleonic Named aIter the Napoleonic- -era surgeon whoera surgeon who described amputations at this level withoutdescribed amputations at this level without ever deIining a speciIic iniury. ever deIining a speciIic iniury.Anatomy Anatomy LisIranc`s ioint: articulationLisIranc`s ioint: articulation between the 3 cuneiIomsbetween the 3 cuneiIoms and cuboid (tarsus) and theand cuboid (tarsus) and the bases oI the 5 metatarsals. bases oI the 5 metatarsals. Osseous stability is providedOsseous stability is provided by the Roman arch oI theby the Roman arch oI the metatarsals metatarsals..Anatomy AnatomyLisfranc's ligament Lisfranc's ligament:: large oblique ligamentlarge oblique ligament that extends Irom thethat extends Irom the plantar aspect oI theplantar aspect oI the medial cuneiIorm to themedial cuneiIorm to the base oI the secondbase oI the second metatarsal. (there ismetatarsal. (there is no notransverse metatarsaltransverse metatarsal ligament Irom 1 to 2) ligament Irom 1 to 2)Anatomy AnatomyInterosseous ligamentsInterosseous ligaments extend Irom the 2 extend Irom the 2nd ndtoto 55th thmetatarsal bases onmetatarsal bases on the dorsal and plantarthe dorsal and plantar aspects. aspects.Secondary stabilizers:Secondary stabilizers: plantar Iascia, plantar Iascia,peroneus longus, andperoneus longus, and intrinsincs intrinsincsAnatomy AnatomyAssociated Structures: Associated Structures:1. Dorsalis pedis artery1. Dorsalis pedis artery courses between 1 courses between 1st standand 22nd ndmetatarsal bases metatarsal bases2. Deep peroneal nerve:2. Deep peroneal nerve: runs alongside the artery runs alongside the arteryMechanisms of Injury Mechanisms of InjuryTrauma: motor vehicle accidents account Ior oneTrauma: motor vehicle accidents account Ior one third to two thirds oI all cases (incidence oI lowerthird to two thirds oI all cases (incidence oI lower extremity Ioot trauma has increased with the use oIextremity Ioot trauma has increased with the use oI air bags) air bags)Crush iniuries Crush iniuriesSports Sports- -related iniuries are also occurring withrelated iniuries are also occurring with increasing Irequency increasing IrequencyMechanisms of InjuryMechanisms of Injury - - Direct Direct- Direct Iniuries: Iorce is applied directly to the LisIranc`s articulation. The applied Iorce is to the dorsum oI the Ioot.- Plantar displacement is more common, but dorsal displacement can also occurMechanisms of InjuryMechanisms of Injury - - Indirect IndirectIndirect iniuries are more common than direct and result Irom axial loading or twisting. Metatarsal bases dislocate dorsally more oIten than plantarly.Associated Fractures Associated FracturesBase oI 2 Base oI 2nd ndmetatarsal metatarsalAvulsion oI navicular Avulsion oI navicularIsolated medialIsolated medial cuneiIorm cuneiIormCuboid CuboidClassification ClassificationQuenu and Kuss (1909) Quenu and Kuss (1909)HOMOLATERAL: most commonClassification ClassificationQuenu and Kuss (1909) Quenu and Kuss (1909)ISOLATEDClassification ClassificationQuenu and Kuss (1909) Quenu and Kuss (1909)DIVERENT: least commomClassification ClassificationMyerson (1986) Myerson (1986)Classification ClassificationMyerson (1986) Myerson (1986)Classification ClassificationMyerson (1986) Myerson (1986)Clinical Findings Clinical FindingsMidIoot pain withMidIoot pain with diIIiculty in weightdiIIiculty in weight bearing bearingSwelling across theSwelling across the dorsum oI the Ioot dorsum oI the IootDeIormity variable dueDeIormity variable due to possible spontaneousto possible spontaneous reduction reductionClinical Findings Clinical FindingsCheck neurovascularCheck neurovascular status Ior compromisestatus Ior compromise oI dorsalis pedis arteryoI dorsalis pedis artery and/or deep peronealand/or deep peroneal nerve iniury nerve iniuryAsses Ior possibleAsses Ior possible COMPARTMENTCOMPARTMENT SYNDROME SYNDROMETreatment TreatmentEarly recognition is the key to preventing long termEarly recognition is the key to preventing long term disability disabilityAnatomic reduction is necessary Ior best results:Anatomic reduction is necessary Ior best results: displacement oI ~1mm. or gross instability oIdisplacement oI ~1mm. or gross instability oI tarsometatarsal, intercuneiIorm, or naviculocuneiIormtarsometatarsal, intercuneiIorm, or naviculocuneiIorm ioints is unacceptable ioints is unacceptable oal: obtain or maintain anatomic reduction oal: obtain or maintain anatomic reductionTreatment TreatmentNonoperative : IorNonoperative : Ior nondisplaced iniuries nondisplaced iniuriesShort leg cast Short leg cast4 to 6 weeks nonweight4 to 6 weeks nonweight bearing bearingRepeat x Repeat x- -rays to rule outrays to rule out displacement asdisplacement as swelling decreases swelling decreasesTotal treatment 2 Total treatment 2- -33 months monthsOperative Treatment Operative TreatmentSurgical emergencies: Surgical emergencies:1. Open Iractures 1. Open Iractures2. Vascular compromise2. Vascular compromise (dorsalis pedis) (dorsalis pedis)3. Compartment syndrome 3. Compartment syndromeOperative Treatment Operative TreatmentTechnique Technique113 dorsal incisions: 3 dorsal incisions:1. 1 1. 1st stincision centered atincision centered at TMT ioint and alongTMT ioint and along axis oI 2 axis oI 2nd ndray, lateral toray, lateral to EHL tendon EHL tendon2. IdentiIy and protect NV2. IdentiIy and protect NV bundle bundleOperative Treatment Operative TreatmentTechnique Technique Reduce and provisionallyReduce and provisionally stabilize 2 stabilize 2nd ndTMT ioint TMT ioint Reduce and provisionallyReduce and provisionally stabilize 1 stabilize 1st stTMT ioint TMT ioint II lateral TMT ioints remainII lateral TMT ioints remain displaced use 2 displaced use 2nd ndor 3 or 3rd rdincision(s incision(s2ndmet. Base unreducedreducedOperative Treatment Operative TreatmentTechnique TechniqueAIter achievingAIter achieving anatomic reductionanatomic reduction positional screw Iixationpositional screw Iixation should be done. should be done.Case Example Case ExamplePre-op APPost-op APPost-op LateralComplications Complications- - Compartment syndrome Compartment syndrome- - InIection InIection- - Neurovascular iniury Neurovascular iniuryMetatarsal Fractures Metatarsal Fractures MOIMOIDirect blow oI a heavy obiect droppedDirect blow oI a heavy obiect dropped onto the IoreIoot and torque related metatarsalonto the IoreIoot and torque related metatarsal shaIt Iractures. shaIt Iractures. Avulsion Iractures oI the base oI the 5 Avulsion Iractures oI the base oI the 5th thmetatarsal are common. metatarsal are common. Stress Iractures at 2 Stress Iractures at 2nd ndand 3 and 3rd rdmetatarsal necksmetatarsal necks and proximal portion oI the shaIt oI the 5 and proximal portion oI the shaIt oI the 5th thmetatarsal are common. metatarsal are common.11st stMetatarsal fractures Metatarsal fractures Anatomy Anatomy- - Shorter and wider than the other metatarsals. Shorter and wider than the other metatarsals.- - Lack oI interconnecting ligament between 1 Lack oI interconnecting ligament between 1st stand 2 and 2nd ndmetatarsals allows independent motion. metatarsals allows independent motion.- - Two powerIul motor attachments to its base Two powerIul motor attachments to its basei) Tibialis anteriori) Tibialis anteriormedial aspect oI basemedial aspect oI base ii) Peroneus longusii) Peroneus longuslateral aspect oI base lateral aspect oI base- - The head oI the 1 The head oI the 1st stmetatarsal supports 2 sesamoid bones. metatarsal supports 2 sesamoid bones.Treatment Treatment No evidence oI instabilityNo evidence oI instabilityclosedclosed management with below knee cast, NWB Ior management with below knee cast, NWB Ior446 weeks. 6 weeks. Presence oI instability or loss oI position oIPresence oI instability or loss oI position oI metatarsal headmetatarsal headtreated with percutaneous treated with percutaneouskk- -wiring or open reduction and screw Iixation. wiring or open reduction and screw Iixation. Severe midshaIt or head communition or openSevere midshaIt or head communition or open IractureIractureexternal Iixation. external Iixation.Central Metatarsals Central Metatarsals Anatomy Anatomy- - The 4 lesser metatarsals are linked to eachThe 4 lesser metatarsals are linked to each other at their bases with a series oI 3 ligamentsother at their bases with a series oI 3 ligaments (dorsal,central and plantar)(dorsal,central and plantar) - - Thick transverse metatarsal ligament connectsThick transverse metatarsal ligament connects metatarsals by linking the plantar plate oI themetatarsals by linking the plantar plate oI the adiacent MTP ioints. adiacent MTP ioints.Treatment Treatment Fractures with 10 degrees angulation alongFractures with 10 degrees angulation along the long axis or 4 mm translation oI shaIt arethe long axis or 4 mm translation oI shaIt are treated with closed management with belowtreated with closed management with below knee cast Ior 4knee cast Ior 46 wks (NWB). 6 wks (NWB). Fractures with ~ 10 degrees angulation or ~ 4Fractures with ~ 10 degrees angulation or ~ 4 mm translation oI the shaIt are treated withmm translation oI the shaIt are treated with closed reduction.closed reduction. Rule out instability oI the LisIranc`s ioint. Rule out instability oI the LisIranc`s ioint. Intramedullary k Intramedullary k- -wiring is done iI there arewiring is done iI there are multiple metatarsal Iractures with signiIicantmultiple metatarsal Iractures with signiIicant communition. communition.Fifth Metatarsal fractures Fifth Metatarsal fractures Anatomy Anatomy- - 55th thmetatarsal has maior motor insertions at itsmetatarsal has maior motor insertions at its base basei) Peroneus brevis attaches on the dorsal aspect i) Peroneus brevis attaches on the dorsal aspectoI the tubercle. oI the tubercle.ii) Peroneus teritius attaches to the dorsalii) Peroneus teritius attaches to the dorsal aspect oI the proximal metaphyseal andaspect oI the proximal metaphyseal and diaphyseal iunction. diaphyseal iunction.Mode of injury Mode of injury- - Maiority oI iniuries are related to sport or athletic activity. Maiority oI iniuries are related to sport or athletic activity.- - Separated roughly into 2 groups Separated roughly into 2 groupsa) Proximal base Iracturesa) Proximal base Iractures b) Distal spiral or dancers Iractures b) Distal spiral or dancers Iractures- - Proximal 1/5 Proximal 1/5th thmetatarsal Iractures are divided by the locationmetatarsal Iractures are divided by the location oI the Iracture and the presence oI prodromal symptoms. oI the Iracture and the presence oI prodromal symptoms.Avulsion or zone 1 injury Avulsion or zone 1 injuryOccurs Irom indirectOccurs Irom indirect load, sudden inversionload, sudden inversion oI the hindIoot withoI the hindIoot with weight on the lateralweight on the lateral metatarsal with tensionmetatarsal with tension alongthe insertion oIalongthe insertion oI the lateral band oIthe lateral band oI plantar aponeurosis. plantar aponeurosis.one 2 injury one 2 injuryTrue Jones Iracture True Jones IractureResults Irom adductionResults Irom adduction oI the IoreIoot resultingoI the IoreIoot resulting in a Iracture at thein a Iracture at the proximal metaphysealproximal metaphyseal diaphyseal iunction oIdiaphyseal iunction oI the bone. the bone.one 3 injury one 3 injuryProximal diaphysealProximal diaphyseal stress Iracture stress IractureOccurs in the proximalOccurs in the proximal 1.5 cm oI the shaIt oI1.5 cm oI the shaIt oI the metatarsal the metatarsalRepetitive cyclic loadsRepetitive cyclic loads as seen in high levelas seen in high level athletesathletesmechanism oImechanism oI iniury iniuryTreatment TreatmentClosed management Closed managementZone 1Zone 1 - - weight bearing as tolerated with hard soleweight bearing as tolerated with hard sole shoe. shoe.Zone 2Zone 2weight bearing cast Ior 8weight bearing cast Ior 810 wks 10 wksZone 3Zone 3NWB Ior 3 months, weight bearing when painNWB Ior 3 months, weight bearing when pain Iree examination Iree examinationSurgical ManagementSurgical Management Open debridment and axial compression withOpen debridment and axial compression with cortical or cannulated sccrew with cancellouscortical or cannulated sccrew with cancellous bone graIting should be done Ior zone 3bone graIting should be done Ior zone 3 iniuries with symptomatic non union. iniuries with symptomatic non union.Injury to the firstInjury to the first Metatarsophalangeal joint Metatarsophalangeal jointAnatomy Anatomy- - Formed by the head oI the 1st metatarsal andFormed by the head oI the 1st metatarsal and proximal phalanx oI the great toe. proximal phalanx oI the great toe.- - Stability is provided by the complex structure oI theStability is provided by the complex structure oI the ioint capsule and ligaments. ioint capsule and ligaments.- - The plantar capsule is a thick weight bearing structureThe plantar capsule is a thick weight bearing structure with strong attachments to the base oI proximalwith strong attachments to the base oI proximal phalanx. phalanx.- - Embeded in the plantar structure are the 2 bonesEmbeded in the plantar structure are the 2 bones known as sesamoids which articulate directly with theknown as sesamoids which articulate directly with the metatarsal head. metatarsal head.- - Medial and lateral sesamoids are the ground contactMedial and lateral sesamoids are the ground contact points Ior weight bearing Ior the 1 points Ior weight bearing Ior the 1st stmetatarsal. metatarsal.- - Between the 2 sesamoids and plantar to theBetween the 2 sesamoids and plantar to the intersesamoid ligament runs the Ilexor hallucis longusintersesamoid ligament runs the Ilexor hallucis longus tendon. tendon. Multiple intrinsic motor insertionsMultiple intrinsic motor insertions at the proximal end oI thisat the proximal end oI this complex control the stability andcomplex control the stability and position oI the ioint position oI the iointi) Medially the medial head oI Flexori) Medially the medial head oI Flexor hallucis brevis inserts into thehallucis brevis inserts into the proximal aspect oI the medialproximal aspect oI the medial sesamoid. sesamoid.ii) The Adductor hallucis partiallyii) The Adductor hallucis partially inserts the medial sesamoid andinserts the medial sesamoid and continues to insert in the medialcontinues to insert in the medial plantar tubercle oI the proximalplantar tubercle oI the proximal phalanx. phalanx.This motor complex providesThis motor complex provides resistance to valgus stress on theresistance to valgus stress on the great toe. great toe. Lateral head oI FlexorLateral head oI Flexor hallucis brevis inserts in thehallucis brevis inserts in the lateral sesamoidandlateral sesamoidand oblique and transverse headsoblique and transverse heads oI Adductor hallucis muscleoI Adductor hallucis muscle insert on the lateralinsert on the lateral sesamoid and continues tosesamoid and continues to insert in the lateral plantarinsert in the lateral plantar tubercle oI proximaltubercle oI proximal phalanx. phalanx. This motor complex resistsThis motor complex resists varus stress applied to thevarus stress applied to the great toe. great toe. The proximal phalanx and the metatarsal headThe proximal phalanx and the metatarsal head are attached by 2 sets oI ligaments are attached by 2 sets oI ligamentsi) Medial and Lateral collateral ligaments i) Medial and Lateral collateral ligamentsii) Medial and Lateral metatarso ii) Medial and Lateral metatarso- -sesamoidsesamoid ligaments. ligaments. Sensations to the great toeSensations to the great toe i) Dorsal i) Dorsal- -medialmedialSuperIicial Peroneal nerve SuperIicial Peroneal nerveii) Dorsal ii) Dorsal- -laterallateralDeep Peroneal nerve Deep Peroneal nerveiii) Plantar iii) Plantar- -medial & Plantar medial & Plantar- -laterallateralby bymedial &lateral plantar hallucal nerves Irommedial &lateral plantar hallucal nerves Irom the Posterior Tibial nerve the Posterior Tibial nerveMode of injury Mode of injury Common in sports Common in sports It is mainly due to axial loading oI the iointIt is mainly due to axial loading oI the ioint HyperdorsiIlexion is called TURF TOE` HyperdorsiIlexion is called TURF TOE` Hyperplantar Ilexion is called SAND TOE` Hyperplantar Ilexion is called SAND TOE`Dorsoplantar translation test Dorsoplantar translation test 4rs45lantar4rs45lantar 1ransalati4n test 1ransalati4n test- - Increased translationIncreased translation compared to thecompared to the contralateral side denotecontralateral side denote signiIicant instability oIsigniIicant instability oI the capsuloligamentousthe capsuloligamentous complex. complex.Classification of Turf toe injuries Classification of Turf toe injuriesSigns andSigns and symptoms symptomsPathology Pathology Treatment Treatment Course Courserade 1 rade 1Plantar andPlantar and medialmedial tendernesstenderness Minimal swelling Minimal swellingNo echymosis No echymosisIntrasubstanceIntrasubstance stretch oIstretch oI capsularcapsular structures structuresRest RestIce IceCompression CompressionElevation ElevationMay play withMay play with protection protectionrade 2 rade 2DiIIuseDiIIuse tenderness tendernessMild to moderateMild to moderate swelling swellingEchymosis EchymosisDecreased rangeDecreased range oI motion oI motionTear oITear oI capsularcapsular structures structuresInclude buddyInclude buddy taping withtaping with above protocol above protocolUpto 2 wksUpto 2 wks loss oI activity loss oI activityrade 3 rade 3Severe diIIIuseSevere diIIIuse tenderness tendernessMarked swelling,Marked swelling, echymosis echymosisMarked decrease inMarked decrease in range oI motion range oI motionCapsular tearCapsular tear with articularwith articular compressioncompression usually dorsally usually dorsallyAdd immobilizationAdd immobilization until able to bearuntil able to bear weight comIortablly weight comIortabllyStiII IoreIoot insertionStiII IoreIoot insertion to resistto resist MTPdorsiIlexion MTPdorsiIlexion336 wks oI6 wks oI loss oI activity loss oI activitySesamoid Fractures Sesamoid FracturesAnatomyAnatomyas discussed beIore as discussed beIore- - They Iunction within the ioint complex as shock absorbers andThey Iunction within the ioint complex as shock absorbers and Iulcrums in supporting the weight bearing Iunction oI the IirstIulcrums in supporting the weight bearing Iunction oI the Iirst toe. toe.- - Their position on either side oI the Flexor hallucis longusTheir position on either side oI the Flexor hallucis longus Iorms a bony tunnel to protect the tendon. Iorms a bony tunnel to protect the tendon.- - Medial plantar branch Irom posterior tibial artery providesMedial plantar branch Irom posterior tibial artery provides vascular supply. vascular supply.Mechanism of injury Mechanism of injuryi) i) Fall Irom height Fall Irom heightii)ii) Hyperpronation andHyperpronation and axial loading as seenaxial loading as seen in ioint dislocation in ioint dislocationFracture !attern Fracture !atterni) i) Transverse IracturesTransverse Iracturesmore common more commonii)ii) Communited and stellate Iractures Communited and stellate Iractures- - Medial sesamoid is more oIten iniured Medial sesamoid is more oIten iniured!artite Sesamoid !artite Sesamoid Occurs due to non union oI one or moreOccurs due to non union oI one or more ossiIication centres during the Iormation oI aossiIication centres during the Iormation oI a sesamoid.sesamoid. Commonly exhibited by the medial sesamoid Commonly exhibited by the medial sesamoidDifferences between !artiteDifferences between !artite Sesamoid and fracture of Sesamoid Sesamoid and fracture of Sesamoid Partite sesamoid Partite sesamoid- - Smooth sclerotic edgesSmooth sclerotic edges - - Sum oI the partite sesamoids parts makes aSum oI the partite sesamoids parts makes a sesamoid larger than a normal one sesamoid larger than a normal oneFracture of SesamoidFracture of Sesamoid Fracture margin is rough and irregular Fracture margin is rough and irregularMinimal separation oI the Iragments due to tightMinimal separation oI the Iragments due to tight support oI plantar plate unless the plate is torn support oI plantar plate unless the plate is tornSum oI the Iracture Iragments should equal a normalSum oI the Iracture Iragments should equal a normal sesamoid size sesamoid sizeFracture Callus apparent on subsequent Iollow ups Fracture Callus apparent on subsequent Iollow upsTreatment TreatmentStable iniuryStable iniurycast immobilization with a toe plate tocast immobilization with a toe plate to prevent dorsiIlexion oI the MTP ioint and NWB Ior prevent dorsiIlexion oI the MTP ioint and NWB Ior446 wks. 6 wks.Prolonged symptoms and Iailed conservative therapyProlonged symptoms and Iailed conservative therapy should be managed with excision oI sesamoid or boneshould be managed with excision oI sesamoid or bone graIting oI the ununited deIect. graIting oI the ununited deIect.!halangeal Fractures !halangeal Fractures Phalangeal Iractures are the most commonPhalangeal Iractures are the most common iniury to the IoreIoot iniury to the IoreIoot Fractures oI the proximal phalanx are commonFractures oI the proximal phalanx are common than Iractures oI the middle and distal phalanx. than Iractures oI the middle and distal phalanx.Mechanism of injury Mechanism of injuryi) i) Direct blow such as heavy obiect droppedDirect blow such as heavy obiect dropped onto the Ioot causes transverse oronto the Ioot causes transverse or communited Iracture.communited Iracture. ii) ii) Iniury resulting Irom axial loading isIniury resulting Irom axial loading is secondary varus or valgus Iorce result in asecondary varus or valgus Iorce result in a spiral or oblique Iracture. spiral or oblique Iracture.Treatment TreatmentNondisplaced IracturesNondisplaced IracturesBuddy`s strappingBuddy`s strapping technique techniqueDisplaced IracturesDisplaced Iracturesclose reduction andclose reduction and immobilization with Buddy technique immobilization with Buddy techniqueOperative reductionOperative reductionross instability or persistentross instability or persistent intraarticular discontinuity intraarticular discontinuityrossly unstable Iracturesrossly unstable Iracturesreduction andreduction and percutaneous k percutaneous k- -wires Iixation which iswires Iixation which is removed aIter 4 wks and Iollowed by buddyremoved aIter 4 wks and Iollowed by buddy strapping until asymptomatic and Iull weightstrapping until asymptomatic and Iull weight bearing. bearing.Compartment syndrome of the foot Compartment syndrome of the footAnatomyAnatomy 9 compartments oI the Ioot 9 compartments oI the IootMedial Compartment Medial Compartment Location : Plantar and medial to 1 Location : Plantar and medial to 1st stmetatarsal metatarsal Contents : Abductor hallucis and FlexorContents : Abductor hallucis and Flexor hallucis brevis hallucis brevisLateral Compartment Lateral Compartment Location : InIerolateral surIace oI the 5 Location : InIerolateral surIace oI the 5th thmetatarsal metatarsal Contents : Abductor digiti minimi, FlexorContents : Abductor digiti minimi, Flexor digiti minimidigiti minimi Central Compartment Central Compartment Divided into SuperIicial and DeepDivided into SuperIicial and Deep compartments compartments- - The deep or calcaneal compartment containsThe deep or calcaneal compartment contains Quadratus plantae muscleQuadratus plantae muscle - - The superIicial compartment contains FlexorThe superIicial compartment contains Flexor digitorium longus and brevis muscles.digitorium longus and brevis muscles. Other Compartments Other Compartments Between each oI the metatarsals lie the dorsalBetween each oI the metatarsals lie the dorsal and plantar interosseous muscles which appearand plantar interosseous muscles which appear to lie in a separate compartment deIined byto lie in a separate compartment deIined by each intermetatarsal space. each intermetatarsal space. The oblique head oI Adductor hallucis lies in aThe oblique head oI Adductor hallucis lies in a Iascial compartment distal and deep to theIascial compartment distal and deep to the quadratus plantae in the plantar aspect oI thequadratus plantae in the plantar aspect oI the IoreIoot. IoreIoot.Treatment Treatment Release oI the Ioot compartments to be doneRelease oI the Ioot compartments to be done under emergency basis. under emergency basis. Three incisional approach is the most reliableThree incisional approach is the most reliable way Ior the release. way Ior the release.Approach Approach- - Two dorsal incisions are placedTwo dorsal incisions are placed 1) medial to the 2 1) medial to the 2nd ndmetatarsalmetatarsal shaIt shaIt2) lateral to the 4 2) lateral to the 4th thmetatarsal shaItmetatarsal shaIt - - Blunt dissection is done betweenBlunt dissection is done between the interosseous muscles andthe interosseous muscles and the Iascia to thedeepthe Iascia to thedeep compartments. compartments.- - The lateral compartment is reachedThe lateral compartment is reached by releasing the Iascia atttached toby releasing the Iascia atttached to the inIerolateral aspect oI the 5 the inIerolateral aspect oI the 5th thmetatarsal through the lateralmetatarsal through the lateral incision incisionApproach Approach The 3 The 3rd rdis a medial incisionis a medial incision to access the medial andto access the medial and central compartments. central compartments. The incision is within theThe incision is within the arch oI the Ioot along thearch oI the Ioot along the muscle oI Abductormuscle oI Abductor hallucis. hallucis. The wounds should beThe wounds should be closed in a secondaryclosed in a secondary Iashion 5Iashion 57 days later. 7 days later.THANK YOU THANK YOUThere is nothing in a caterpillar that tellsThere is nothing in a caterpillar that tells you it`s going to be a butterIly` you it`s going to be a butterIly`- -Buckminster Fuller Buckminster Fuller