Pathologic & Traumatic Classifications of the Foot & Ankle Handbook Edition 2002 Association for Podiatric Medical Research & Review Se California College of Podiatric MedicineAssociation for Podiatric Medical Research & Review Pathologic & Traumatic Classifications of the Foot & Ankle Handbook Edition 2002 ee Edited by David Collman, DPM California College of Podiatric Medicine - Class of 2002 Revision Assistance by Sandeep Patel, DPM Contributors CCPM Class of 2002 Chuck Ananian, DPM. Brynn Hoffman, DPM David Carmack, DPM Ciaran Jacka, DPM Keenan Carriero, DPM Jennifer Jansma, DPM Ricky Childers, DPM Gita Jhala, DPM Dean Clement, DPM Tyler Marshall, DPM David Collman, DPM Farshid Nejad, DPM John Dawson, DPM. Sandeep Patel, DPM Josh Garrison, DPM Leslie Rowe, DPM Matt Garrison, DPM Quinton Solomon, DPM Greg Grant, DPM Kirsten Van Voris, DPM Spencer Heninger, DPM Eugene Zarutsky, DPM esAssociation for Podiatric Medical Research & Review Pathologic & Traumatic Classifications of the Foot & Ankle Handbook Edition 2002 This handbook has been compiled by the Association for Podiatric Medical Research & Review at the California College of Podiatric Medicine. It is designed to serve as a quick-reference guide for the more common pathologies and traumatic injuries in the foot and ankle. It is not comprehensive. Nearly all classifications are based on original sources. Although every effort has been made to ensure accuracy, the contributors take no responsibility for errors. ‘The reader is encouraged to further research the systems included in this handbook, as well as others, in an effort to advance their understanding of injury classifications germane to the foot and ankle. Ultimately, such understanding may advance communication between foot and ankle specialists and improve outcomes in patient care. This handbook is intended for use by all students of podiatric medicine, Acknowledgement Iam grateful to my classmates for their willingness to contribute to this project and help see it through to completion. I am especially thankful for their acceptance of my motivation and madness. I wish you all the very best in the years ahead. David Collman, DPM CCPM Class of 2002 PGY-1, San Francisco Bay Area Foot & Ankle Residency Kaiser Hospital Consortium/VASFee Pathologic & Traumatic Classifications of the Foot & Ankle i Table of Contents Neuropathies.... Reflex Sympathetic Dystrophy Malignant Melanoma... Charcot Osteoarthropath; Burs.. Puncture Wounds. Gun Shot Wounds..... Closed Fractures... Open Fractures.. Nail Trauma. First MTPJ Dislocation Injury... Hallux Limitus & Rigidus... Avascular Necrosis of the 2 Metatarsal .. S™ Metatarsal Fractures .. Tarsometatarsal (LisFranc’s) Fracture-Dislocation Navicular Fractures ..Fractures of the Talus Talar Dome Lesions... Talar Neck Fractures. Talar Body Fractures. Posterior Medial & Lateral Talar Tubercle Fractures .. Fractures of the Calcaneus ‘Calcaneal Fractures... Anterior-Superior Process Fractures... Ankle Injuries Anterior Tibiotalar Spurs. Ottowa Rules. Lateral Ankle Ligamentous Injuries Ant/Post Inferior Tibiofibular Ligament Avulsion Injuries Tibiofibular Diastasis.. Maisonneuve Fracture. Bosworth Fracture... Ankle Fractures... Pilon Fractures .. Epiphyseal Fractures... Tarsal Coalition Subtalar Joint Dislocation . Subtalar Joint Arthroereisis Tibialis Posterior Dysfunction... Peroneal Tendon Dislocation .... Tendo Achilles Radioopaque Lesions... Tendo Achilles Rupture...Perlman MD, Leveille D, Trauma Eponyms Gale B: Traumatic classifications of the foot and ankle. J Foot Surg 28(6):551, 1989. Dates of origin are listed in italics. Ashurst’s Sign: Aviator’s Astragalus: Bosworth’s Fracture: Chaput’s Tubercle: ‘Cooperman’s Fracture: Cotton’s Fracture: Dupuytren’s Fracture: . Hawkins Sign: Jones’ Fracture: Lis Frane’s Ligament: The overlap of the anterior tibial tubercle and the medial 2/3 of the distal fibula normally found on AP ankle x-ray. The sign is present when this overlap diminishes secondary to widening of the ankle mortise that results from disruption of the anterior infererior tibiofibular ligament, often producing tibiofibular diastasis. 1922. Fracture-dislocation of the talar neck from a dorsiflexion injury as described by Anderson in 19/9. The proximal aspect of a fibular fracture is locked behind the posterolateral ridge of the tibia, making closed reduction impossible. 1947, ‘The anterolateral tubercle of the distal tibia, named in 1908. Salter-Harris triplane type IV epiphyseal fracture consisting of two fragments: the first composed of the tibial shaft, medial malleolus, and and anteromedial portion of the epiphysis; the second composed of the remainder of the metaphysis, epiphysis, and attached fibula. 1978. Fracture of the medial malleolus, fibula, and posterior aspect of the distal tibia, also termed a trimalleolar fracture. 1915, An avulsion fracture of the medial malleolus or deltoid ligament tear, a short oblique fracture of the fibular shaft, and a tibiofibular diastasis, 1839. Radiolucency present in the subchondral area of the talar dome seen 6 to 8 weeks status-post talar neck fracture dislocation on an AP ankle x- ray. This sign rules out asecptic necrosis of the talar body. 1970. A transverse fracture of the proximal diaphysis of the fifth metatarsal. 1902. ‘The dorsal ligament that attaches the base of the second metatarsal to the medial cuneiform.Maisonneuve’s Fracture: A spiral fracture of the proximal diaphysis or neck of the fibula. Poland’s Hump: Pott’s Fracture: Ring of Lacroix: Shepherds Fracture: 1840. The anteromedial aspect of the distal tibial epiphysis humps up superiorly and indents the corresponding point of the adjoining ‘metaphysis, visualized on x-ray at 4 to 5 years of age. 1898. AA fracture of the distal fibula and disruption of the deltoid ligament or a medial malleolar fracture (also termed bimalleolar fracture in this case). 1775, An osseous ring extension of the ‘metaphyseal cortex at the area of the ephiphyseal plate. It provides support and stability to the physis. Fracture of the posterolateral tubercle of the talus. 1882, ‘Thurston-Holland’s Sign: The spike of metaphyseal bone attached to the fractured epiphysis Tillaux Fragment: Volkmann’s Fracture: Wagstaff’s Fracture: Zone of Ranvier: seen in Salter-Harris Type Il fractures. 1929. A type Ill epiphyseal injury of the anterolateral distal tibia. 1872, A fracture of the posterolateral comer of the distal tibia — Volkmann’s Triangle ~ medial malleolus, and fibular shaft, presenting with tibiofibular diastasis. 1875. A vertical fracture of the anterior margin of the lateral malleolus from an avulsion of either the anteroinferior tibiofibular or anterior talofibular ligaments. 1875. The circumferential groove surrounding the periphery of the epiphyseal plate that functions to provide appositional growth at the periphery.B. Hoffman Neuropathies: Seddon; Sunderland > Seddon Seddon HJ: Three types of nerve injury. Brain 66:238, 1943. Seddon classification of nerve injuries. Br Med Jour 2:237, 1942. Neuropraxia — disruption of myelin sheath + Nerve contusion with temporary blockage of salutatory nerve conduction Etiology: blunt trauma or compression, Large diameter, high speed nerve fibers with thick myelin sheaths are most susceptible. Deep tendon reflexes, skeletal muscle function, vibratory and two-point discrimination may be lost while pain, temperature, and autonomic function remain, Repair can take days to months and is usually perfect because only the myelin must regenerate, Axonotmesis ~ disruption of myelin sheath and axon + Wallerian degeneration without severing nerve Etiology: prolonged compression, traction, ischemia, toxins. Axonotmesis affects myelinated and unmyelinated nerve fibers equally. The distal portion of the axon undergoes Walllerian degeneration (distal axon degradation via phagocytic Schwann cells). ‘The proximal portion of the axon and nerve cell body help with axon regeneration. Regeneration ‘occurs at a rate of 1 mm per day. Because the endoneural scaffold and supportive sheath remain intact, the budding neurite can grow down its corresponding distal endoneural tube. Functional recovery is generally good, but diminishes as the distance from the point of injury to the end organ increases. The more proximal the lesion, the less likely it is that normal function will return because proximal lesions affect a wider distribution and convey a worse prognosis. __ Neurotmesis - disruption of myelin sheath, axon, and supportive connective tissue ‘+ Complete nerve transection Etiology: sectioning injuries such as laceration, gunshot wound, open fracture, severe traction or avulsion, puncture, and injection of toxin. Since distal endoneural tubes are disrupted, it is hard for budding neurites to bridge the defect and grow into their corresponding endoneural tubes to properly innervate end organs. Any regeneration that does occur is confused because the neurites tend to grow into other endoneural tubes. Neurectomy is an example, The distal segment is excised and budding neurites have no chance of achieving reinnervation.> Sunderland Sunderland S: Nerves and Nerve Injuries, 2 Ed, Churchill Livingstone: New York, 1978. 1 Degree: 2°* Degree: 3" Degree: 4" Degree: 5" Degree: - conduction defect without Wallerian degeneration or axonal disruption - axonal disruption with Wallerian degeneration distal to the point of trauma - no breech of endoneurium ~ positive Tinel’s sign ~ regeneration likely - disruption of axon, Schwann cells, and internal fasicle organization ~ irregular regeneration - disruption of axons and fascicle incomplete severance of the nerve ~ regeneration rare, possible neuroma in continuity ~ complete severance of the nerve with gap between nerve endings ~ regeneration unlikely, neuroma likely main artery epineurium to nerve perineurium nerve trunk endoneurium and axons, fascicleQ. Solomon Reflex Sympathetic Dystrophy (RSD) Lankford L, Thompson J: Reflex Sympathetic Dystrophy, upper and lower extremity: diagnosis and management. AAOS Instructional Course Lectures 26:163, 1977. RSD is a disorder involving sympathetic innervation of an extremity, characterized by severe burning pain, hypersensitivity, vasomotor instability, trophic skin changes, and patchy/spotty osteoporosis. As much as 50% of the time RSD occurs after trauma, minor or major, and the other 50% of the time history of trauma is absent. ‘Symptoms Burning pain out of proportion Edema Vasomotor instability (hot, cold, discolored, or patchy) Hyperhydrosis Osteopenia (Sudeck’s atrophy) Skin and soft tissue atrophy Stiffness/contractions Stage I: Acute Phase soft tissue edema redness increased heat pronounced pain with reluctancy for movement hyperesthesia to light touch hypethydrosis spotty osteoporosis after 3-4 weeks (Sudek’s atrophy) duration 1-3 months Stage II: Dystrophic Phase swelling becomes brawny edema after approximately 3 months motion continues to decrease as joints fibrose continued spotty osteoporosis (Sudek's atrophy) cyanotic appearance of extremity duration 3-6 months Stage III: Atrophic Phase cool dry pallor to skin skin tightly stretched and wax-like pronounced diffuse osteoporosis on x-ray stiffness and disability 6-9 months after injury usually irreversibleJ. Dawson Melanoma Stay Clark; Breslow > Clark’s Level of Pathologic Staging Clark Jr. WH, From L, Bernardino EA, Mihm MC: The histogenesis and biologic behavior of primary human malignant melanomas of thesSkin. Cancer Res 29:705, 1969, ‘*Based upon the anatomic level of the lesion Stage Location I within epidermis 0% w penetrates papillary dermis 4% Wm fills papillary dermis to reticular dermis 33% Vv enters reticular dermis 61% v invades subcutaneous fat B% > Breslow’s Classification of Survival Rates Breslow A: Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Annals of Surg 172:902, 1970. *Based upon tumor thickness Stage Thickness Syyr recurrence rate ‘Survival rate 1 <0.75 mm. 0% . 83-100% 2 0.76-1.50 mm 33% 37-90% 3 151-225 mm 32% 37-83% 4 2.26-3.00 mm 75% 44-72% 5 >3.00 mm. 88% 9-55% “Prognosis of melanoma is a function of both tumor thickness and stage of invasion. The Probability of recurrence may be helpful in selecting patients for prophylactic lymph node dissection.M. Garrison Wound Classification: UTHSCSA University of Texas Health Science Center at San Antonio: Diabetic Wound Classification System Lavery LA, Armstrong DG, Harkless LB: Classification of Diabetic Foot Wounds. J Foot Ankle Surg 35(6):528, 1996, Grade o IL mm pre-ulcerative areas wound involving wound involving or previous ulcer sites not including tendon or capsule bone or joint tendon, capsule, bone but not bone . Stage A B c. D_ non-ischemic non-ischemic non-infected ischemic, infected wound clean wound infected wound ischemic wound Example: A Grade IU-D wound represents a wound penetrating to bone or joint with active infection and vascular compromise, Therefore, this system accounts for not only the depth of the ulceration, but also assesses the wound for infection and peripheral arterial occlusive disease. a Infected wound: frank purulence and/or two or more local or systemic signs of infection including erythema, lymphangiitis, lymphadenopathy, edema, pain, and loss of function; systemic signs include F/C/N/V and generalized malaise Ischemic wound: one or more of the following clinical signs: claudication, rest-pain, absent pulses, skin atrophy, absence of pedal hair, dependent rubor, or pallor on elevation; non-invasive vascular study criteria include transcutaneous oxygen <40mmHg, ABI <0.80, or absolute toe systolic pressure <45 mmHgJ. Garrison Ulcer Classifications: Wagner; Gibbons; Knighton > Diabetic Foot Lesions: Wagner ‘Wagner FW: The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 2(2): 64, 1981. The Wagner system classifies diabetic foot lesions with regards to lesion depth, presence of infection, and tissue necrosis. It establishes a treatment protocol for each lesion, Note: The ischemic index is calculated by dividing the lower extremity blood pressure by the brachial blood pressure (e.g. ABI). Grade 0: no open skin lesion present; may include bony deformity, charcot changes, healed lesion sites, and previous amputations ‘Tx: doppler ultrasound to assess vascular status and possible revascularization to area if ischemic index is < 0.45; medical treatment - C & S with appropriate antibiotic coverage Grade 1: _partial-thickness ulcer with no deep structure involvement (bone, joint, ligament, muscle); may include deformity, joint changes, and previous amputations ‘Tx: same as Grade 0 Grade 2: full-thickness ulcer with deep structure involvement; usually includes bony deformity ‘Tx: same as Grades 0 & 1, but debridement/skin grafts and correction of underlying deformity become more necessary Grade 3: full-thickness ulcer with deep structure involvement, includes abscesses, osteomyelitis, erythema, and edema ‘Tx same as Grades 0-2 with mandatory operative debridement Grade 4: full-thickness ulcer with deep structure involvement, includes wet/dry gangrene isolated to the toes and forefoot “Lx same as Grades 0-3 with mandatory removal of necrotic tissue below the ankle Grade 5: full-thickness ulcer with deep structure involvement, includes wet/dry gangrene to entire foot ‘Tx same as Grades 0-4 with mandatory removal of necrotic tissue above the ankle> Diabetic Ulcers: Gibbons Gibbons GW: ‘Diabetic Foot Infections,’ The Diahetes Educator, Summer 1992, The Gibbons system classifies diabetic ulcers with regards to their depth and severity of infection, and like the Wagner system, establishes a treatment protocol. In even mild infections, research indicates that an average of 3 micro-organisms are cultured. This indicates the importance of proper antibiotic coverage. Mild ~partial-thickness ulcer Tx: =no cellulitis = no bone involvement Moderate - full-thickness ulcer Te: -<2mm cellulitis = (H/-) bone involvement ~ possible limb loss ~ full-thickness ulcer Te: ->2 mm cellulitis - CH) bone involvement ~ possible limb loss ~ systemic toxicity > Non-Diabetic Ulcers: Knighton test of injured limb, C & S, broad- ‘spectrum PO antibiotics, wound care hospital admission, glucose control, C& S, broad spectrum IV antibiotics, surgical debridement, wound care, possible revascularization/amputation same as moderate (No original source found; information based on Total Recall) The Knighton system classifies ulcers with regards to ulcer depth and tissue necrosis. Level: _partial-thickness ulcer Level I: _fall-thickness ulcer _ Level HI: Level IV: with or without osteomyelitis Level V: Level VI: gangrene to surrounding tissues full-thickness ulcer with deep structure involvement (bone, joint, ligament,muscle) full-thickness ulcer with deep structure involvement, including abscesses full-thickness ulcer with deep structure involvement and including wound necrosis. full-thickness ulcer with deep structure involvement, including wound necrosis andL. Rowe Osteomyelitis: Cierny-Mader, Waldvogel Mader JT, Ortiz M, Calhoun JH: Update on the diagnosis and management of osteomyelitis, Clin Pod Med Surg 13(4): 724, 1996. > Clerny-Mader ~ based on anatomy and physiology Anatomic stage 1, Medullary OM — confined to intramedullary bone, usually by hematogenous spread 2, Superficial OM — true contiguous focus infx from bone lying at base of soft tissue wound 3. Localized OM ~ cortical sequestration, can be removed without compromising stability 4. Diffuse OM - through & through, requires resection of bone, results in bone instability Physiologic stage A. Normal host B. Compromised host (systemically, locally, or both) C. Treatment morbidity worse than the disease Diagnosis: Gold Standard — bone biopsy, usually considered OM if wound probes to bone ‘Treatment; Stage 1 child: Abx alone are usually sufficient due to good bone vascularity. Stage 1 adult: Abx & Sx - 4 weeks of abx given from initiation of treatment or last sx. Stage2: —Abx & Sx~2 weeks of abx following superficial debridement. Stage 3 & 4: Abx & Sx-4-6 weeks of abx following last surgical debridement. > Waldvogel — based on etiology 1. Hematogenous OM 2. Contiguous Focus OM 3. OM associated with vascular disease 4, Chronic OMC. Jacka Osteoarthopathy Frykberg RG: Osteoarthropathy. Clin Pod Med Surg 4:351, 1987. Charcot Osteoarthropathy - as described by Bichenholz Stage I Developmental Stage II Coalescence Stage III Reconstruction Clinical: red, hot, swollen foot ~ active disease process. Radiography: joint effusion, intra-articular fx, debris formation, dislocations, osteochondral fragmentation; bone resorption: phalangeal “hour glassing”, metatarsal “pencil sharpening.” Histology: osseous debris embedded into synovium. ‘Scenario: continued WB => vicious cycle of repetitive trauma, further joint laxity & distention, deformity, increased inflammation & hyperemia ~> bone resorption = more susceptible to fracture. Healing phase Radiography: absorption of osseous debris, fusion of fragments, sclerosis of bone ends, Continued Healing Phase Radiographically: bone ends & major fragments become rounded; revascularization reduces degree of sclerosis ‘Scenario: revascularization and remodeling of bone ends as body's attempt to restore joint architecture UlD. Collman Charcot Osteoarthropathy Patterns: Sanders & Frykberg; Schon >Sanders & Frykberg: Anatomic Pattem Sanders LJ, Frykberg RG: Diabetic neuropathic ostevarthropathy: The Charcot foot. In Frykberg ze (ea: ‘The High Risk Poot in Disbces Mellitus. New York: aan Livingstone, 1991. [as Stes Metra a | ‘~~. iS, Sy > Schon: Midfoot Deformity Pattern Schon LC, Weinfeld SB, Horton GA, Resch S: Radiographic and clinical classification of acquired midtarsus deformities. Foot Ankle Int 19:394, 1998, i This system classifies midtarsus deformity based on the anatomic location, assessed by radiographic type (I-IV), correlated with the extent of collapse by clinical stage (A-C). Typel: Lisfranc Type: Naviculocuneiform Type Ill: Perinavicular Type IV: Transverse Tarsal = eee S.C 2) ORGIES OGG. hala Burns Tuerk D: Burns and Frostbite, in Scurran BL (ed), Foot and Ankle Trauma, 2™ Ed., Churchill Livingston: New York, 1996, The skin is the largest organ of the body, comprising 15% of the total body weight. Severe burns can destroy all the layers of the skin causing hypovolemia, a hypermetabolic state increasing catabolism and weight loss, and infection from normal flora as well as pathogenic organisms. Because of the potential morbidity and fatality that can result from burns, the ability to identify the degree of burn injury is crucial to appropriately treating the patient. 1 Degree: _ Partial-thickness injury of superficial layer of epidermis; erythema, no blistering Clinical: Painful erythema without blister formation (i. . sunburn) 2™ Degree: Partial-thickness injury of the deeper layers of the epidermis ‘Superficial — does not totally destroy the basal cell layer fluid accumulation causes painful blister formation; usually heal because of sparing of basal cell layer Clini Deep — involves much of basal cell layer but leaves hair follicles & sweat glands intact. Glinical: may or may not have blister formation; may be dry and anesthetic; mottled appearance; prolonged healing resulting in thin, unstable epithelium. 2° degree buns should heal within 2-3 weeks. 3" Degree: Full-thickness injury with destruction of the skin and its appendages (hair follicles, sweat glands, and sebaceous glands); includes electric/radiation frostbite Clinical: Leathery consistency with whitish to dark. color; may have thrombosed vessels present; patients are insensitive to touch and pinprick. Healing ‘occurs only by migration of intact skin margins around the bum wound. *Wounds that heal within a reasonable amount of time are termed partial-thickness, while ‘wounds that take more time are termed full-thickness. Los The heat from a burn precipitates body response to local tissue injury. Heat can denature Proteins, lyse cell membranes, interfere with enzymatic cell reactions, and cause hemodynamic changes. Cell death may occur from coagulation necrosis. Cells with reversible damage must be Protected from further insults, such as infection or thermal/mechanical trauma, Prevention of ‘dehydration can also decrease the depth of tissue necrosis, 12‘Treatment Protocol ‘The feet, eyes, ears, hands, face, and perineum are considered critical areas. Patients with >5% of the critical areas burned should be managed as inpatients. 1. Cessation of burning process and maintenance of adequate airway 2. Treatment of associated injuries (bleeding, fractures, etc.) 3. Wrap in clean linen and transport to hospital 4, Fluid resuscitation: the quantity of fluid needed is proportional to body size (kg) and extent of burn as a measure of total body surface area (BSA), which about 4mL per 1% TBSA. During the first 24 hrs administer plain lactated Ringer’s solution without dextrose. After the capillary leak seals, administer protein (usually albumin) and 5% dextrose in water. 5. Assess the circulatory status of the bumed extremity, especially for circumferential burns. The constricting eschar in these patients may require escharotomy and/or fasciotomy. This may be done without anesthesia because the eschars are anesthetic. Administer tetanus prophylaxis following the standard guidelines. Administer routine antibiotic coverage (controversial): a brief course of penicillin (or erythromycin for PCN allergies) can be given, though some believe this makes the patient more susceptible to severe superinfection from yeasts and resistant bacteria. 8. Burn wounds can be initially covered with sponges soaked in cool (not iced) water. Be sure to wash the wound with mild soap, 9. Broken blister should be debrided. Unbroken blisters may be left intact (unless the patient is non-compliant or at risk for infection from the wound) 10. The burn may be covered with topical antibiotic cream (SDS, sulfamylon, 5% AgNO3, gentamicin, and providone-iodine). 2™ degree bums can be treated with medicated gauze (ie. Xeroform). The wound should be dressed QD or BID. Debridement must remove eschar, surface fibrinous exudates, non-viable tissue, broken blisters, etc. Wet-to-dry dressings may be used as a source of mechanical debridement, 11. Pain control is important to assure patient compliance. “moun tepoemapectteg nonesnssm Outpatient care consists of occlusion of the wound and g Ga). _ elevation of the extremity to prevent edema formation. 4 so Long-term care consists of physical therapy with active fim) i ( consists of physical therapy with active ROM to by fb ——ha prevent joint stiffening. Elevation will reduce edema, : ff [m\ \ i \\,, Use of ‘night splints, orthoses, and other positioning ‘ devices will help prevent joint contracture. WB activity may help prevent heel cord shortening. Hypertrophic | scars may be treated with intralesional steroid injections or grafting, Linear contractures can be treated with Z- i} plasties. tp Skin grafts ‘"* mad For 3" degree wounds or wounds that take longer than 2-3 weeks to heal, a graft should be performed. Non-viable tissue should be removed; infection should be controlled; and a recipient bed should be established with enough vasculature to support a graft. Do not debride below the paratenon or periosteum, or else the bed will not support the graft. as 13F. Nejad Puncture Wounds: Green & Bruno Green NE, Bruno J: Pseudomonas infections of the foot after puncture wounds. Southern Medical Journal 73(2): 146, 1980, This study evaluated 10 children with Pseudomonas bone and joint infections. The necessity for tetanus prophylaxis is well understood in medicine, so tetanus is almost nonexistent. This classification examined how medical intervention at differing stages of the infection was critical for whether or not sequelae was present, and if so, to what degree. ‘Type: Early diagnosis with early surgical drainage and debridement and adequate antibiotic coverage resulted in complete healing without any permanent bone or joint damage. . Type IE: Diagnosis and treatment are delayed for 9-14 days. The infection will be eradicated with debridement and adequate antibiotic coverage, but there may be residual bone and joint destruction. ‘Type IMI: Diagnosis and/or treatment are delayed for 3 weeks or more and the infection becomes chronic, necessitating bone resection for final cure. Pseudomonas bone and joint infections of the foot after nail puncture wounds present a typical picture of initial pain and swelling from local trauma that subsides within 2-3 days, allowing the child to retum to normal activities. If at this point the symptoms worsen rather that resolve, Pseudomonas infection is likely. If the puncture wound is superficial, only local wound care is necessary. If the wound is deep, exploration and debridement in the emergency room are necessary. The wound should be left open and antibiotic therapy should be instituted. ItS. Heninger Gunshot Wounds: Sherman & Parrish; Ordog Sherman RT, Parrish RA: Management of shotgun injuries: a review of 152 cases. J Trauma 3: 76, 1963. Ordog GJ, Sheppard GF, Wasserberger JS, et al: Infection in minor gunshot wounds. J Trauma 34:358, 1993. > Sherman and Parrish Type: ‘Type I: Type II: > Ordog Type 0: Typel: ‘Type: ‘Type MI: Type IV: _Typev: Type VI: ‘Type VII: Occur at distance greater than 7 yards Penetrate subcutaneous tissue or deep fascia Occur at 3-7 yards Viscera, bone, and vascular system violated Occur at less than 3 years, blast-type injury Severe local destruction and loss of tissue No injury (suspicion of injury, e.g., blood spatter from another victim) Blunt injury (non-penetrating gunshot wound, e.g., with bulletproof vest, thick clothing/shoe gear) Graze injury (abrasion, injury to epidermis, superficial dermis) Blast effect without missile penetration (bullet missed, blank ammunition at very close range) Blast effect with missile penetration Penetrating: A — laceration through dermis, B — subcutaneous, C — all deep structures, D body cavity, E - more than body region Perforating (through and through): A — laceration, B - subcutaneous, C — all deep structures, D — body cavity violated, E - more than one body region Penetration with missile embolizationTetanus 0.5 ml toxoid if previous immunization, and 250 units of tetanus immunoglobulin + 0.5 mi of toxoid if no previous immunization. Bullet not excised unless superficial and palpable. Foreign bodies removed only if excessive dissection is not required to get to the object. ‘Adhere to Gustilo’s priniples for open fractures: if >8 hrs. consider infected most low velocity are type I Recommended abx are 1* gen. Cephlasporin and an Aminoglycoside for three days or until infection subsides Surgical debridement: Gustilo I & I< 8 hrs can close primarily Any question — leave open until no sign of infection (3-7 days)S. Patel Closed Fractures: Rockwood & Green Rockwood CA: Rockwood and Green’s Fractures in Adults, Vol. 1, 1996, Direct Trauma — application of force to the fracture site Tapping Fractures: Force of dying momentum is applied over small area. Presents as a transverse fracture line with only one bone involved. Minimal soft tissue damage. Crush Fractures: Bone is extensively comminuted or broken transversely. Extensive soft tissue damage. Involves both bones in leg and forearm. Penetrating (Gunshot) Fractures: Produced by projectiles. Velocity of the projectile hhas more influence than mass. [Low velocity: Minimal soft tissue damage. Missile may splinter the shaft of Done or embed in cancellous end. IL High velocity: Extensive soft tissue damage. Fragments of bones are tumed into secondary missiles. Indirect Trauma — fractures produced by a force acting at a distance from the fracture site Traction or Tension Fractures: The fracture line is transverse. It is an avulsion type fracture, i.e., the medial malleolus maybe pulled off by the deltoid ligament in eversion and external rotation injuries of the ankle, The fracture line is usually perpendicular to the line of pull, although it can be at 45 degrees. Angulation Fractures: Transverse fracture caused by bending forces in a long bone. When a bone is bent, the convexity undergoes a tension stress and the concavity undergoes compression. Somewhere in between there is a neutral zone. Bone is stronger in compression than in tension, therefore the convexity fails first, producing a transverse fracture line. Commonly, the concavity side will fail at an angle to the main fracture line breaking offa triangular fragment of variable size. Rotational Fractures: Cause a characteristic spiral fracture, Each end of the spiral fracture has a vertical component, which is where the fracture is initiated. Rotational fractures occur in two stages. In stage I, there is an increasing number of cracks in the cortex. In stage II, maximum torque is attained, and propagation of failure of the cracks results ina spiral fracture. Compression Fractures: The hard shaft of the long bone is driven into the cancellous end, producing a T- or Y-shaped fracture. Less commonly, compression in the longitudinal axis of the tibia produces a longitudinal fracture known as a “teacup” fractures. These do not displace and require no treatment. Angulation and Compression Fracture: Fractures are often produced by a combination of forces. A curved fracture line is produced. The oblique component is caused by compression and a transverse component is caused by angulation, Sometimes, a fragment of bone bearing the oblique surface is shear off, forming a butterfly fragment. te* Angulation and Rotation Fracture: This combination of forces produces an oblique fracture, These are often confused with a spiral fracture, However, the broken ends of a spiral fracture are long and sharp whereas in the oblique fracture, they are short, blunt, and round. Also, with a spiral fracture, gaps cannot be visualized, regardless of the orientation of the radiograph. Treatment Closed Reduction: Preferred to be done early, since swelling increases 6-12 hours after injury. Swelling of the limb will pose a barrier to adequate reduction. If early reduction cannot be achieved, wait a few days for the swelling to subside. ntraindicatioy ion 1. No significant displacement. 2. No reduction possible due to communition. 3. Reduction can’t be held by external immobilization. 4. Fracture produced by traction force. 5. Open fracture, Indications for Open Reduction 1, Fracture cannot be reduced by closed manipulation. 2. Displacement of articular surface. 3. Traction forces resulting in an avulsion fracture. 4. Ifischemia of the foot does not resolve after closed manipulation. 5. Multiple adjacent fractures. Technique for Closed Reduction 6-12 hours after injury, or a few days after swelling decrease. Anesthesia to prevent pain and muscular guarding. Understand the mechanism of injury. Distraction along long axis of the bone with assistant applying counter-traction. Disengagement of the ends of the fracture by recreating the fracture deformity. This relieves the tension on the soft tissue. 6. Rotation deformity is corrected. 7. Apposition of the bone fragments. 8. 9 veer . Angulation deformity is reduced. . Apply immobilization. A cast applied directly after injury should be checked the following day to make sure there is no compromise in circulatory status. infection, delayed union, malunion, limb length discrepancy due to shortening, avascular necrosis, joint stiffness. * Soft Tissue: injuries to nerves and vessels, 18S. Patel Open Fractures: Gustilo & Anderson Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty- five open fractures of long bones. J Bone Joint Surg 58-A(4):453, 1976. Scurran BL (ed): Foot and Ankle Trauma, 2nd Ed., Churchill Livingston: New York, 1996, Typel: Clean wound less than 1 cm long. Little soft tissue damage with no crushing component. Simple transverse or short oblique fracture with minimal comminution, ‘Type: _Laceration more than 1 cm long with no extensive soft tissue damage. Moderate amount of contamination. Simple transverse or short oblique fracture with minimal comminution. ‘Type I: — Wound greater than 5 om long with extensive soft tissue damage to muscle, skin, and neurovascular structures. Associated with severe crush component and severely comminuted fracture. Marked contamination. Examples include farm injuries, gunshot wounds, traumatic amputations, and open fractures greater than 8 hours old. Type IITA: adequate soft tissue coverage of the fracture with limited periosteal stripping, ‘Type IIIB: extensive soft tissue injury with periosteal stripping, considerable bone exposure. ‘Type ITIC: associated with arterial injury. Reported amputation rate of 25-90%. ciples of Treatment . All open fractures should be treated as an emergency. . Evaluate patient for other life threatening injuries. . Appropriate antibiotic therapy. }. Tetanus prophylaxis, Adequate debridement and irrigation. . Stabilization of fracture, . Early cancellous bone grafting. Appropriate wound coverage. Rehabilitation, SPINWASENE 4Antibiotic Therapy Antibiotic therapy is considered therapeutic rather than prophylactic. Cultures should be taken from deep tissues after thorough irrigation and debridement. Antibiotic therapy is administered after cultures are taken and should be given within the first three hours of injury. ‘Type I: cephalosporin Type: cephalosporin or cephalosporin plus an aminoglycoside. If any question about the cleanliness of the wound, an aminoglycosie is added to the cephalosporin. Type: —_cephalosporin plus aminoglycoside Farm injuries: Penicillin G Isicati Type I: Irrigated with 1-2 L of solution ‘Type II & Il: Irrigated with 2-4 L of solution All type III wounds should be checked again in 24 to 48 hours. Wound Coverage Primary Closure: Indicated in type I and the majority of type II open fractures Delayed Primary Closure: Defined as closure of the wound within 3-10 days. Indicated for type III open fractures. Note: + An immediate amputation may be necessary if there is a severely crushed or devitalized muscle and skin or loss of the neurovascular supply to the involved part. + Immediate stability offers relief of pain, ease of patient care, and early mobility of the extremity. 20L. Rowe Nail Trauma: Rosenthal; Malay > Rosenthal Rosenthal EA: Treatment of fingertip and nail bed injuries. Orthop Clin North Am 14:675, 1983 Zonel: _ distal to bony phalanx y Zone: distal to lunula Zone UI: proximal to distal end of lunula Direction of nail bed tissue loss: A. Dorsal oblique B. Transverse guillotine C... Plantar oblique D. Tibial or fibular axial E i. Central gouging 9 > Malay Malay DS: Trauma to the nail and associated structures. In McGlamry ED (ed): Comprehensive Textbook of Foot Surgery. 2" Ed. Williams & Wilkins: Baltimore, 1992, 1, Primary onycholysis 2. Subungual hematoma 3. Simple nail bed laceration 4. Complex (stellate) nail bed laceration 5. Nail bed laceration with phalangeal fracture 6. Nail bed and toe tip tissue loss, including nail bed avulsion, partial digital amputation, and digital degloving aB. Hoffman First MTPJ Dislocation Injury: Jahss Jahss MH: Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1(1):15, 1980. The two dislocation types show displacement of the base of the proximal phalanx above the first metatarsal. Jahss noted two distinct patterns of sesamoid position after the injury. The sesamoid position of one in relation to the other is variable and defines the type of dislocation present. Mechanism: 1 MTPJ hyperextension (motor vehicle accident, falls from heights, sports injuries) ical ion: hallux is dorsally subluxed at the MTPI with the first metatarsal head prominent plantarly pain is elicited on attempted ROM and palpation of the involved joint extensor apparatus is in a contracted state and the flexor apparatus is tightened flexed attitude of the HIPJ may be present deformity may be subtle because of masking caused by the swelling that follows the injury eoeee ‘Typel: - transverse capsular rupture plantar to metatarsal head/neck with the proximal phalanx, plantar capsule, and sesamoids displaced dorsally on metatarsal head - retrograde plantar directed force of phalanx drives met head ina plantar direction, HIPJ becomes fixed in plantarflexion. ~ intersesamoidal ligament remains intact, sesamoids do not fracture, ‘Type IIA: - dorsal dislocation of proximal phalanx with intersesamoidal ligament rupture and sesamoid subluxation to each side of the ‘metatarsal head; sesamoids do not fracture ‘Type IIB: - dorsal dislocation of proximal phalanx, sesamoids displaced ‘medial & lateral to the metatarsal head ~ transverse avulsion fracture of one of the sesamoids - Type TIC: intersesamoidal ligment ruptures ( |; usually irreducible on closed reduction, the metatarsal head being incarcerated by the conjoined tendons with their intact sesamoids. ‘Type 2: sesamoid disruption usually permits closed reduction, Mayo block, distraction, and pushing the proximal phalanx into a congruous relation with the metatarsal head. Repair soft tissue insult with suture. Correction is maintained with a slipper cast or BK cast for 3-4 weeks, then a surgical shoe for an additional 3 weeks. Resistant deformity requires surgical repair. Type IB injury should be casted BK for 6 weeks NWB. 22Q Solomon & D. Colman Hallux Rigidus: Ragnauld; Drago, Oloff, & Jacobs; Hattrup & Johnson; Hanft There is no agreed upon value for normal I MIPJ range of motion. Generally, limitation below 65-75 degrees is considered pathologic. The term hallux rigidus characterizes this pathology, though hallux limitus is commonly used to describe progression of the disorder. Etiology ‘Metatarsus primus elevatus Long 1 ray Long 2™ ray / Short 1" ray (Morton’s foot) Hypermobile 1* ray Immobile 1° ray Long hallux proximal phalanx Paralytic deformities Trauma ‘Uncompensated varus: forefoot, hindfoot Sesamoid ankylosis Tatrogenic Symptoms Radi Findings + Pain + Joint space narrowing + Decreased 1" MTPJ dorsiflexion + Joint flattening and enlargement + Crepitus + Osteophytic lipping + Dorsal bunion + Subchondral sclerosis and/or cysts + HIPThallux extensus + Invraarticular/periarticular debris + Hyperkeratosis: sub-hallux IPJ, sub-2™ met, lateral column > Ragnauld Ragnauld B: The foot: pathology, aetiology, seminology, clinical investigation and therapy. New York: Springer-Verlag, 1986. 1 Degree: - limitation of 1 MTPJ dorsiflexion to 40 degrees -pain at end ROM + slight joint space narrowing - decreased convexity of metatarsal head - periarticular spurring + absence of structural sesamiodal disease2nd Degree: - arthrosis - enlargement of joint - more painful ROM, loss of ROM - crepitation - narrowing of joint space ~ flattening of joint surfaces ~ increased periarticular spurring ~ hypertrophy of sesamoids. 3rd Degree: -ankylosis -crepitation little or no motion with pain -loss of joint space -marked hypertrophy of joint -loose bodies -marked sesamoid involvement. > Drago, Oloff, & Jacobs Drago JJ, Oloff L, Jacobs AM: A comprehensive review of hallux limitus. J Foot Surg 23:213, 1984, Grade I - Stage of Functional Limitus (minimal adaptive changes) Hallux equinus/flexus, metatarsus primus elevatus, plantar subluxation of proximal phalanx, significant pronatory component to rearfoot, pain at the end of ROM but no DID. Note that 1* MTPJ dorsiflexion may be normal NWB but GRF elevate I* met and limit motion. Grade II - Stage of Joint Adaptation (proliferative, destructive joint changes develop) Flattening of the Ist metatarsal head, osteochondral defect/lesion possible, limited passive ROM, pain at end of ROM, small dorsal exostosis, subchondral eburnation, eriarticular lipping of both the proximal phalanx and Ist metatarsal head. Grade III - Stage of Joint Deterioration/Arthritis Established Arthrosis Severe flattening of 1st metatarsal head, osteophytic production (especially large dorsal exostosis), nonuniform narrowing of joint space, crepitus, pain on full ROM, degeneration of articular cartilage, subchrondral bone cysts, Grade IV - Stage of Ankylosis Obliteration of joint space, loose bodies within joint or capsule, less than 10° 1" MTPJ ROM, associated inflammatory arthritis, total ankylosis may occur (asymptomatic). 24> Hattrup & Johnson Hattrup SJ, Johnson KA: Subjective results of hallux ridigus following treatment with cheilectomy. Clin Ortho Rel Res number 226: 182, 1988, GradeI: _- Mild to moderate osteophyte formation - Joint space preservation Grade II: - Moderate osteophyte formation - Joint space narrowing - Subchrondral sclerosis, Grade III: - Marked osteophyte formation - Loss of visible joint space - With or without subchondral cyst formation > Hanft et al Hanft JR, Mason ET, Landsman AS, Kashuk KB: A new radiographic classification for hallux limitus. J Foot Ankle Surg 32(4):397, 1993. ‘This system incorporates subchondral & sesamoid pathology and establishes a surgical algorthim. Grade I + Metatarsus primus elevatus + Mild dorsal spurring & sclerosis surrounding MTPJ Grade II — elements of Grade I plus: + Broadening & flattening of 1 metatarsal & proximal phalanx + Decreased joint space, dorsal & lateral osteophyte formation Grade IIB — elements of Grade II plus: + Osteochondral defects, loose bodies, and subchondral cyst formation _ Grade III — elements of Grade I plus: + Severe flattening of 1* metatarsal and proximal phalanx + Severe sesamoid hypertrophy + Minimal joint space + Severe dorsal & lateral spurring + Severe osteophyte formation + Severe angular deformity may be present Grade IIIB — elements of Grade III plus: + Osteochondral defects, loose bodies, and subchondral cyst formationSurgical algorithm for treatment (Hianft et al) — 87% satisfaction rate (retrospective study) Grade I: Grade I: A Grade TB: A. Grade: A Grade IB: A > wow ww aacaa vuouy vs tot on tot vas aa = Key Chielectomy (moderate) Chiclectomy (extensive) Metatarsal or phalangeal osteotomy Sesamoid release Joint decompression (Regnauld) Chondroplasty & removal of loose bodies Total joint replacement Arthrodesis/Keller osteotomy HoOMmoawDT. Marshall Avascular Necrosis of the 2nd Metatarsal: Freiberg; Smillie > Freiberg Freiberg AH: Infraction of the second metatarsal bone. Surg Gynecol 19:191, 1914, Also known as osteochondrosis of the metatarsal head or avascular (aseptic) necrosis of the bone; most commonly affects the 2" metatarsal. no DID; articular cartilage intact periarticular spurs; articular cartilage intact severe DJD; loss of articular cartilage epiphyseal dysplasia: multiple head involvement 1, Trauma, or trauma followed by fracture 2. Ischemia 3. Prominent plantar metatarsal head with excessive loading, with compromise to the subchondral bone circulation 4. Often appears after age 13, affecting women 3x more frequently than men Signs and ms, Pain in the MTPJ, usually dorsal; either sharp, dull, or aching in character . Edema with increased activity . Limitation of motion of the involved digit and MTPJ Palpable irregularities may be present dorsally Distal distraction of the toe will cause pain Adjacent MTPJ hyperkeratoses may be present as the involved metatarsal bears less weight Se eeNe xy evaluatioy |. Initial findings include joint space widening 3-6 weeks after the onset of symptoms Then followed by increased density of subchondral bone As the disorder progresses, a zone of rarefaction develops surrounded by a sclerotic rim With time, the epiphyseal bone weakens and collapses with the formation of spicules and loose bodies Flattening of metatarsal head with osteophytic lipping Joint narrowing Peripheral soft tissue swelling Sclerotic bone margins Pepe ena 2s‘Treatment 1. Conservative: directed toward preventing further damage and displacement of the MTPJ: casting and cortisone shots, followed by orthoses 2. Surgical: later stages a. Implant arthroplasty if symptoms are due to joint arthritis b. Metatarsal head remodeling: must preserve digital alignment - use postoperative splint for 3 months ¢. Smillie advocates bone grafts to restore the contour of the metatarsal head by inserting a cancellous graft, good for stages I-III 3. Rotational osteotomies (Gauthier and Elbaz): rotate the lower aspect of the metatarsal head dorsally after the section of damage cartilage has been excised. This allows the plantar cartilage to articulate with the proximal phalanx. > Smillie ‘Smillie IS: Freiberg’s infraction. J Bone Joint Surg 39-B: 580, 1957. Stage I: Fissure fracture. The epiphysis is ischemic at this point but undetectable on plain radiographs until an increase in bone density occurs. Stage II: Absorption of bone. Central aspect of bone sinks into the metatarsal head. ‘The articular cartilage may show a change in contour. Stage III: Further progression with projections remaining on either side of the metatarsal head. The plantar articular cartilage remains intact. Stage IV: Fractures and loose bodies may occur. Plantar cartilage is no longer intact. Stage V: Flattening of the metatarsal head and arthrosis SOP Soff So Sy NY 26M. Garrison Fifth Metatarsal Fractures: Stewart; Torg; Chapman > Stewart Stewart, IM: Jones’ Fracture: fracture of the base of fifth metatarsal. Clin Orthop 16:190, 1960, This classification evaluates the fracture location and assesses AVN and/or joint involvement, Two systems are presented below: the first has been popularized while the latter is the trac radiographic classification. System I { Typel Type a) Type IT a) : TypeIv TypeV TypeIA Jones fracture Comminuted Jones fx 2F Type TA Styloid process fx Classic Jones facture. Occurs at the iaphyseal-metaphyseal junction or the distal limit of the 4"-5" metatarsal joint. idered extraarticular. Intraarticular fracture of the 5" met base. Extraarticular avulsion fracture of the styloid process. Intraarticular comminuted fracture. Extraarticular avulsion of epiphysis, children only, Longitudinal fragment. Type UB Intraarticular styloid fx> Torg — based on radiographic examination ‘Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity. J Bone Joint Surg 66(A):209, 1984, This classification includes evaluation of the medullary canal thereby assessing the need for bone grafting procedures. Treatment of choice for type I fractures is NWB BK cast, for type Il fractures is time with immobilization or medullary curettage and autogenous inlay bone-grafting for athletes to expedite healing, and for type III fractures is bone-grafting procedures. Distal) Base Fractures of the Sth Metatarsal Type ~ acute fractures with the absence of intramedullary sclerosis ~ typically have narrow-sharp fracture margins ~no hx of previous fi - minimal cortical hypertrophy of periosteal reaction to chronic stress ‘Tx: NWB BK cast TypeIl _- fractures with delayed union and evidence of intramedullary sclerosis ~ widened fx margins involving both cortices ~ hx of previous injury or fx - increased evidence of periosteal new bone formation ‘Tx: immobilization or medullary curettage plus autogenous inlay bone-graft for athletes to expedite healing ‘Type _- fractures with non-union and complete obliteration of the medullary canal by sclerotic bone ~ hx of repetitive trauma and recurrent symptoms ~ periosteal new bone formation ‘Tx: bone-graft procedures > Chapman (source not found) “TypelA: acute non-displaced fracture at ‘metaphyseal-diaphyseal junction (Jones Fracture) ‘Type IB: Jones fracture, displaced or comminuted Typell: _clinical/radiographic evidence of prior injury non-union or delayed union Type IA or IB Type MIA: _non-articular styloid process fracture ‘Type HIB: _ intra-articular styloid process fracture 28B. Hoffman Tarsometatarsal (Lisfranc’s) Fracture-Dislocation: Hardcastle (Quenu & Kuss) Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W: Injuries to the tarsometatarsal Joint: incidence, classification and treatment. J Bone Joint Surg 64B:349, 1982. The Hardcastle classification system is based on radiographic examination. It incorporates the Patterns of injury identified by Queno & Kuss, Lisfranc’s fracture-dislocation was classically considered an equestrian injury that occurs as the foot is caught in a stirrup of a falling rider, Today, the majority of cases are from industrial injuries or motor vehicle accidents. ‘Type A: total or homolateral incongruity Disruption of the entire TMJ in the sagittal or transverse plane with displacement of all of the metatarsals. This is the most common type of TMI dislocation. et ype a mene ‘Type B: partial or isolateral incongruity There is dislocation of only a portion of the ‘TMI in the sagittal and/or transverse planes. ‘Type Bl: Medial displacement of 1* ‘metatarsal alone or with metatarsals 2,3,4. The 5* metatarsal is unaffected. ‘Type B2: Lateral displacement of one or more of the lesser metatarsals. The 1* metatarsal is unaffected, ‘Type C: divergent the lesser mets are either partially (C1) or totally (C2) dislocated laterally in the sagittal and/or transverse planes, ‘The first met is dislocated medially and J Past Sfp Dlpacement TYPE C, TYPE C, a4Anatomy ‘+ Lisfranc’s ligament is the strong interosseous ligament that attaches the medial cuneiform to the 2! metatarsal base. It may cause an avulsion fracture of the medial base of the 2™ metatarsal, known as the “fleck sign.’ The dorsal and plantar ligaments that attach the medial cuneiform to the 2" met base are often to be considered part of the Lisfranc’s complex. + All metatarsal bases except 1 & 2 are attached by transverse dorsal and plantar ligaments. ‘There is no ligament between the bases of the 1" metatarsal and the lesser metatarsals. The lesser mets dislocate as a unit and the 1* metatarsal may or may not dislocate with them. + The ligaments between the lesser tarsus and metatarsals are stronger plantarly than dorsally. + The dorsal medial cuneiform-1" met ligament is the largest and may be repaired primarily. Mechanism + The incidence of tarsometatarsal fracture-dislocations is rare (0.2% of all fractures). + Direct injuries result from a direct blow to the joint complex (crushing force) + Indirect injuries are more frequent and result from forced abduction of the forefoot or from loading the plantarflexed foot. Examples include the MVA with forced braking and the axial force applied to plantarflexed foot (sports injury where one player falls onto the heel of another's plantarflexed foot). Other indirect injuries include twisting, the result of combined abduction and plantarflexion. Examples include falling from a horse with foot in stirrup. Diagnosis Missed in 20% of cases — late treatment generally correlates with poorer function. High index of suspicion necessary for anyone complaining of midfoot pain. Clinically, the foot appears edematous and ecchymotic about the midfoot. AP, MO, and lateral radiographs, with contralateral films: 1. Appreciation of diastasis between the medial cuneiform and 2 metatarsal base. Normally the medial border of the second metatarsal is continuous with the medial border of the middle cuneiform, with the space between the 1* and 2" mets equal to the space between the 1" and 2” cuneiforms. (AP view) 2. Disruption of the normal continuity between the medial border of the 4 met and the medial border of the cubiod, and between the lateral border of the 3" met and the lateral border of the lateral cuneiform. (MO view) 3. Dorsal displacement of the metatarsals relative to the tarsals. (Lateral view) Stress films may be warranted if plain films are inconclusive with clinical suspicion. Treatment + This injury is a medial emergency. Edema control, monitoring of distal blood supply, and ruling out compartment syndrome is critical to minimize morbidity. ‘+ The literature supports ORIF with anatomic reduction and 6-8 weeks immobilization to minimize morbidity. K-wires vs. screws, open vs, percutaneous, and fixation placement are debated. 30Wilson, JN: E. Zarutsky Navicular Fractures: Watson-Jones ajuries of the Foot,” Watson-Jones Fractures and Joint Injuries, 6 Ed., Churchill Livingstone: New York, 1982, ‘Type I: ‘Type I: Tuberosity fracture + May be an isolated fracture or an avulsion by the posterior tibial tendon during acute eversion. + Must be distinguished from a congenital os tibiale externum and possible MTJ subluxation should be considered. ‘Tx: Immobilization x 4 weeks Dorsal lip fracture + A small bone flake may be avulsed from the dorsal surface of navicular with plantarflexion followed by forced inversion or eversion. ‘Tx: Short immobilization period (4 weeks). If there is CC joint injury or MTJ subluxation, longer immobilization is needed (6 weeks) ‘Transverse body fracture with dorsal fragment dislocation. + Fracture is in the horizontal plane resulting in a large dorsal and small plantar fragment. + Mechanism is a longitudinal thrust along the metatarsal rays while the ankle is in equinus. ‘Tx: Manipulation (closed reduction), skeletal transfixation, open operation. Improper management or failure of closed reduction/ORIF can lead to loss of “keystone” of the medial longitudinal arch and eventual progression to flatfoot deformity. This complication may be salvaged only by TN and NC arthrodesis. 3J. Dawson Transchondral Talar Dome Fractures: Berndt-Hardy Berndt AL, Harty M: Transchondral Fractures (Osteochondritis Dissecans) of the Talus. J Bone Joint Surg 41-A:989, 1959. Misnamed “Osteochondritis Dissecans,” loose bodies produced by spontaneous necrosis without disease, tumor, or trauma, The defect actually results from a shearing of the distal tibia and talar dome under compression, often secondary to an ankle sprain or fracture. It frequently goes unnoticed since it can occur without notable trauma and pain. Normal reduction and immobilization may not yield a bone union. It is most difficult to recognize in acute phase, due to the similar symptom presentation of an ankle sprain. The symptoms of the chronic phase are those of osteoarthritis. /A\ Stage I: Subchondral bone compression (A) ae (\\ 8 ‘Stage II: Partially detached osteochondral fragment (B) Stage LI: Completely detached, non-displaced fragment (C) z Stage IV: Displaced osteochondral fragment (D) 7 7 ce Anterolateral lesion (incidence = 44%) A result of ankle inversion with dorsiflexion, This shallow wafer-shaped lesion at the middle to anterior half of the talar domes lateral border is best visualized with a mortise view of the ankle joint. ‘Posteromedial lesion (incidence = 56%) A result of ankle inversion with plantarflexion. This deep cup-shaped lesion at the posterior 1/3 of the medial talar dome is best visualized with an AP view of the ankle joint. ‘Treatment © Stage I, IL, & Ill-medial ~ 6-12 weeks of BK NWB cast immobilization * Stage [lateral & IV - Surgical fragment excision, crater curettage, and drill hole fenestration to subchondral bone to aid revascularization & stimulate fibrocartilage production. Followed by 6-12 weeks of BK NWB cast immobilization. Larger fragments can be treated with reduction and internal fixation. A malleolar osteotomy may be required for adequate exposure, though arthroscopy may be utilized instead. All stages should be rehabilitated with early passive NWB ROM. 32D. Carmack Talar Neck Fractures: Hawkins, Canale & Kelley Hawkins, L: Fractures of the neck of the talus. J Bone Joint Surg. 52-A(5): 991, 1970, Canale TS, Kelley Jr. FB: Fractures of the neck of the talus. J Bone Joint Surg. 60-A: 143, 1978. The purpose of this classification is not only to describe the extent of the injury but also to allow the physician to confidently predict the prevalence of avascular necrosis (AVN). Type I: _nondisplaced vertical fracture of the talar neck. ‘Type II: displaced vertical fracture of the talar neck with dislocation of the STJ. ‘Type III: displaced vertical fracture of the talar neck with dislocation of the STJ & AJ. ‘Type IV: displaced vertical fracture of the talar neck with dislocation of STJ, AJ, & TNJ. (Canale & Kelley) 1 i 1 s + Blood Supply Head & Neck: artery of sinus tarsi (from perforating peroneal and DP artery) Body: artery of tarsal canal (from PT & deltoid branch) - post. talus: calcaneal branches + Inci Type Incidence Blood Supply Interruption AVN of Body Ty 120%) a. sinus tarsi rare (0-15%) T 42% a. sinus tarsi & tarsal canal 42% (15-50%) MM 34% a, sinus tarsi, tarsal canal, deltoid branches 91% (90-100%) IV 4% all arteries 391% + AVN of head 3+ Mechanism: forced dorsiflexion and hyperextension of the foot. Injuries typically the result of high impact trauma in car, motorcycle, and plane accidents. + Treatment: Vascular status is the most important consideration in patient evaluation, especially those with type III or IV injuries. The mechanism of this injury can cause the talar body to displace posteromedially, thereby disrupting the neurovascular bundle in the tarsal tunnel and eliminating 80% of the blood flow to the foot. 'NWB cast 6-8 weeks ‘; attempt closed reduction; if unsuccessful, ORIF via anteromedial approach with screw fixation through the head and neck of the talus perpendicular to the fracture Tine. © Healing is represented by the “Hawkin’s Sign” which is subchondral radiolucency around the fracture site, indicating revascularization, detectable 6-8 weeks following injury. Patient may require long-term immobilization and NWB to attempt to revascularize, or ultimately fusions (pantalar, triple arthrodesis, isolated), bone grafts, and possibly amputation, * Aggressive osteochondral drilling of a radiopaque talus may provoke revascularization in some cases and is therefore a consideration before arthrodesis, 3¢S. Heninger Talar Body Fractures: Sneppen ‘Sneppen O, Christensen SB, Krogsoe O, et al: Fractures of the body of the talus. ACTA Orthop Scand 48:317, 1977. Group I: Transchondral or compression fracture of the talar dome (including osteochodritis dessicans of the talus). Group Transchondal Dome Fractures ‘Ste sep Sage v Group HI: Coronal, sagittal, or horizontal shearing fractures involving the entire talar body. (Caused by severe dorsiflexion with compressive forces. Body of the talus must be sandwiched between the tibia and calcaneus, Rare injury.) ‘Type 1: Coronal or sagittal fracture TA: nondisplaced IB: displacement of trochlear articular surfaces IC: displacement of trochlear articular surface with associated STI dislocation. ID: total dislocation of talar body (displacement of STI & AJ). ‘Type I: Horizontal fracture TA: nondisplaced, dividing the talar body into superior and inferior halves. IIB: displaced, superior portion shifts on the inferior portion, (Group tt Shear Fractures a Sooita Herzorial ‘Treatment: - Nondisplaced tal; -BK NWB cast 6-8 wks. ~ Displaced talar bod ~ closed reduction or ORIF, BK NWB cast x 6-8 wks, followed by 6-8 wks. BK WB cast if no signs of AVN or delayed/non union. 35Group II: Group IV: Group V: Fracture of the posterior tubercle of talus. Steida’s process or Shepherd’s fracture; s trigonum syndrome. Note that the lateral tubercle of the posterior process of the talus has a secondary center of ossification. ~ Caused by severe plantarflexion of the foot. ~ Pain in posterior ankle causing limited ROM, which can often be reproduced with FHL movement. ~ Treatment: injectional therapy local/steroid every 3 wks, BK WB cast x 6wks, or surgical excision of lateral tubercle. Fracture of the lateral process of the talus. Crush fracture of the talar body. Group Group: Poster Tubercle Fractures Lara Process FracturesR. Childers Posterior Tubercle of Talus Fractures: Cedell; Watson & Dobas Posterior Medial Tubercle Fracture > Cedell Cedell C: Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Acta Orthop Scan 45:454, 1974, Pertinent Anatomy + Posterior talotibial ligament (deep deltoid) inserts into posteromedial talar process + Posterior talocalcaneal ligament Mechanism ‘* Sudden dorsiflexion and pronation with rupture of the posterior talotibial ligament and avulsion of portion of posteromedial tubercle of the talus + Direct trauma to the posteromedial ankle Clinical Findings + Presents as sprain + Medial pain with discoloration and swelling at the ankle joint + Bony formation and tender area behind the medial malleolus representing fragment of the posterior medial tubercle of the talus + Large avulsion fragment may impinge on course of FHL tendon: pain on hallux ROM + Tarsal tunnel syndrome secondary to tibial nerve entrapment by avulsed fragment « (+) Tinel’s Sign + dysesthesia/hypoesthesia + AP & Lateral Ankle CX ‘Treatment + Non-displaced/minimally displaced fragment: RICE, BK NWB cast immobilization x 6 weeks + Large displaced fragment: ORIF + Communited fracture or non-union (pseudoarthrosis): fragment(s) excision 3Posterior Lateral Tubercle Fracture >Watson & Dobas (Source not found) ‘Shepherd in 1882 reported on three cases of what he believed to be fractures and denounced the notion of a secondary talar ossification center. Later that year, Turner was the first to claim the os trigonum was a secondary center of ossification. Lapidus in 1975, and Thle and Cochran in 1982, reported cases of a fracture of the fused os trigonum. The os trigonum, first visualized on radiography between 8-10 years of age, may be a separate ossicle or fused to the talus, calcaneus, or both, unilateral or bilateral, or bipartite. While such variation may confound diagnosis, the literature finds it more often fused than not, and fracture 10 be uncommon. The system of Watson and Dobas classifies the anatomical variation of the posterolateral process of the talus but does not stage its injury. Type: normal posterior lateral talar process with no clinical significance ‘Type II: enlarged posterior lateral tubercle of talus known as Steida’s process ‘Type III: accessory bone or os trigonum that may be irritated by trauma ‘Type IV: os trigonum with cartilaginous or synchondrotic union with the talus Pertinent Anatomy + Posterior talofibular ligament Mechanism + Sudden plantarflexion or repeated extreme plantarflexion (McDougall A: The os trigonum. J Bone Joint Surg 37B:257, 1955.) + Patient presents with foot in equinus and valgus. + Pain about the ankle, often exacerbated by hallux ROM (course of FHL tendon) + AJROM may be restricted by muscle spasm + Crepitation and local ecchymosis anterior and lateral to tendo Achilles insertion Radiography + Lat Ankle (B/L) + Free os trigonum typically round and smooth in appearance + Fractured os trigonum visualized by serrated and rough features ‘Treatment + BK WB cast x 6 weeks Surgical excision if pain persists 38D. Carmack & K.Carriero Fractures of the Calcaneus: Soeur & Remy; Sanders; Zwipp; Rowe; Essex-Lopresti There is a large history and controversy over the treatment of calcaneal fractures. In past years calcaneal fractures were treated via closed reduction and cast immobilization, The standard of care today is ORIF via ASIF principles. The goal of ORIF is restoration of height, length, and width by the re-approximation of articular surfaces. The architecture of the STJ and CCI must be completely restored to minimize morbidity. There are many pioneers in the classification and treatment of calcaneal fractures. Refer to Clinical Orthopedics & Related Research, 290: 2-167, 1993, for more detailed coverage of this topic. Incidence: Most common tarsus fracture (approx. 60%) with 75% of cases involving the STJ; associated injuries common (spine, extremities). Mechanism: Axial load drives the talus into the calcaneus, most commonly associated with Falls from a height, followed by motor vehicle accidents, Glinical:. __Mondor’s sign, wide and shortened heel, inability to bear weight. Lateral plain film demonstrates two angles essential for diagnosis: 0} * Bohler’s (Tuber) Angle: normal = 20-40° (1 in fracture) “> measures depression of posterior facet * Critical Angle of Gissane: average = 130° ( in fracture) > Soeur & Remy — utilized in Europe Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg 57B:413, 1975. This system classifies calcaneal fractures based on the number of fragments, determined by Broden views on conventional plain-film radiography. It is based on ihe premise that the lateral Process of the talus acts as a wedge, entering the calcaneus and forming the primary fracture “Tine. The thalamic portion of the calcaneus is that part which supports the posterior facet. ‘Type I: Non-Thalamic Fractures (Extra-Articular) — 17% Anterior End 4% Medial Tubercle 4% Lateral Tubercle 2% Calcaneal Body 3% Sustentaculum Tali 1% Plantar Spur 3% Posterior Beak 2% 34‘Type I: Thalamic Fractures (Intra-Articular) - 83% First Degree: Shearing Alone 36% (tx: closed reduction) Second Degree: Shearing + Compression 56% (tx: ORIF) ‘Third Degree: | Comminuted 2% (tx: ORIF) > Sanders Sanders, R, Fortin, P, DiPasquale, T, Walling, A: Operative Treatment in 120 Displaced Intraarticular Calcaneal Fractures. Clin Orthop Rel Res 290: 87, 1993. The Sanders system based on the concept established by Soeur and Remy, but utilizes CT to determine the location and fracture lines through the posterior facet and the resulting number of articular fragments produced by injury. It serves as a guide for surgical repair and is usefid in determining the prognosis for the given injury. I= Lateral 2=Central 3= Medial + Talus is divided into 3 equal columns by 2 lines (A & B), which separate 4 Sustentculi the posterior facet into 3 separate pieces — medial, central, and lateral. ‘A third fracture line (C) corresponding to the medial aspect of the talus separates the posterior facet from the sustentaculum, creating 4 potential fragments. +» Fracture lines are named A, B and C from lateral to medial. Type: — nondisplaced articular fracture of posterior facet (regardless of # of fx lines) ‘Type TI: 1 fracture line across posterior facet creates 2 fragments 3 fracture types based on fracture line location: II-A — most lateral fx line II-B ~ central fx line I-C — most medial fx line “Type TMI: 2 fracture lines across posterior facet create 3 fragments, with depression of the central fragment. TH-AB ~ lateral + central fx line TH-AC = lateral + medial fx line TH-BC ~ central + medial fx line ‘Type IV: 3 fracture lines create 4 or more fragments (comminution) ABC ~ lateral, central, + medial fx lineAB Type MAB. d Sd Type HAC BC ‘Type ‘Type MBC BS Ay Typel¥ Gg) ‘Treatment The main objective is restoration of the architecture of the calcaneus by re-establishing the height and width of the heel, and relocating the posterior facet to its anatomical position, Typel: NWB cast x6-8 weeks Type I-IV: _ ORIF via lateral hockey stick (Palmer) incision to maintain peroneal tendons and sural nerve in flap. > Zwipp (Hannover scheme) — surgical classification and planning system, gaining popularity Zwipp J, Tscheme H, Thermann H, et al. Osteosynthesis of displaced intraarticular fractures of the calcaneus: results in 123 cases. Clin Orthop Rel Res 290:87, 1993. This system divides calcaneus fractures into two to five main fragments and correlates them with the number of involved joints based on a 12-point scale. This system facilitates evaluation of the extent of injury and the complexity of surgical restoration of calcaneal architecture. Itis therefore useful for determining injury prognosis. 41Calculate Fracture Score ~ assign 2 -12 points based on: «+ # of fragments + # of involved joints + add 1-3 points for open fracture or closed with high soft tissue injury * add 1 point for highly comminuted fracture or fracture of talus, cuboid, navicular fracture 2Fragments/0 Joint - 2 points 2Fragments/1 Joint - 3 points 3Fragments/1 Joint - 4 points 4Fragments/1 Joint - 5 points 4¥Fragments/2 Joints - 6 points 5 Fragments /3 Joints - 7 points Fragment/Joint Additive Fracture Classification Diagram: key for incisional approach: © = medial incision - McReynold type lateral incision — Palmer type bilateral incisions i , 3 i 2 ‘| : I Omedial @ bilateral + ext. lateral Fic. 1. Fragment/joint classification. The five main fragments are: | = sustentaculum, 2 = tuberosity, 3 = subtalar joint fragment, 4 = ani i int fragment. The three joints in order of frequency of involvement are: | = posterior subtalar joint, 2 = calcaneocuboid joint, 3 = anterior subtalar joint (middle and anterior joint facet). 42> Rowe: primarily utilized for extra-articular fractures Rowe CR, Sabellarides HR, Freeman PA. Fractures of the os calcis: a long term study of 146 patients. JAMA 184:98, 1963. Rowe — Extra-articular: closed reduction if stable fracture, ORIF if displaced or unstable Type IA: calcaneal tuberosity fracture medial: more common, heel everted on fall, abductory force Tateral: heel inverted on fall, adductory force ‘Type IB: sustentaculum tali fracture tenderness on hallux movement b/e of FHL course ‘mechanism: - excessive eversion on fall from height - force on medial foot with valgus heel Type IC: anterior superior process fracture — intra- or.extra-articular ‘most common, often improperly dx as ankle sprain x mechanim: - avulsion via bifurcate ligament - plantarflexion force on a supinated foot Essex-Lopresti — describes intra-articular fractures: tongue type & joint depression Essex-Lopresti, P: The mechanism, reduction technique, and results in fractures of the os calcis. BrJ Surg 39: 395, 1951-52, Mechanism: . Vertical fall - tongue type . Posterior fall — joint depression pe Fall from height + talus driven into calcaneus, creating 1° fracture line that extends from the apex of the Critical Angle of Gissane to the plantar cortex of the calcaneus. 2° fracture line depends on the direction of force: + Vertical force -+ 2° fx line extends posteriorly from 1° line to the posterior calcaneal cortex producing the tongue type fracture. = 1<<, “i. / * Posterior force > 2° fx line extends posteriorly from 1° line and exits on the superior aspect of the calcaneus, surrounding the posterior facet and causing it to impact into the body of the calcaneus, exploding it medially and laterally into fragments. ‘Type I: Tongue Type Fracture Type Ui: Joint Depression Fracture YH Note: Tongue-type fractures are infrequent. The Sanders & Zwipp systems are superior for intra-articular fracture classification and prognosis. 44R. Childers Anterior-Superior Fractures of the Calcaneus: Degan Degan TJ: Surgical excision for anterior-process fractures of the calcaneus, J Bone Joint Surg 64-A:519, 1982, Type: _undisplaced fracture involving only the tip of the anterior process (most common) Type Ui: displaced extra-articular fracture ‘Type III: large displaced intra-articular fragment, involving C-C joint Note: injury also generally classified as Rowe Type IC fracture ertinent iy + Bifurcate ligament \ + Portion of the EDB muscle + Inferior extensor retinaculum * C-C joint Mechanism + Forced plantarflexion & inversion: avulsion fracture + Forced dorsiflexion & eversion: compression fracture ++ Presents as sprain (frequently misdiagnosed as ankle sprain) ot + Pain and swelling at dorsolateral aspect of midfoot + Peroneal spasticity + Tenderness approximately 2 cm anterior and 1 cm inferior to the ATF ligament + Most useful diagnostic feature for this injury Radiography + AP, Lat, MO foot + Best viewed obliquely with central beam directed 10°-15° ‘superior and posterior to midfoot Anterior process promontory cannot be visualized until age 10 + RO accessory ossicles: calcaneus secundarium and cuboides secundarium ‘Treatment « RICE + Small displaced fragment: NWB immobilization x 4 weeks + Large displaced fragment: ORIF + Fragment excision for non-union (pseudoarthrosis) 45T. Marshall Anterior Tibiotalar Spurs: Scranton & McDermott Scranton Jr, PE, McDermott JE: Anterior tibiotalar spurs: a comparison of open versus arthroscopic debridement. Foott Ank Intl 13(3):125, 1992, Etiology The mechanism of injury is extreme ankle dorsiflexion with resultant anterior joint impingement and posterior joint distraction. This repeated dorsiflexion is thought to cause anterior sub- periosteal hemorrhage and subsequent sclerotic bone proliferation. The spurs can form on either the tibia or talus. Recurrent ankle sprains further exacerbate this condition. ‘Type I - Synovial Impingement X-ray shows an inflammatory reaction, up to 3mm spur formation. Dorsiflexion stress films indicated in types I & II: stress film confirms impingement. Increased anterior soft tissue swelling. Magnetic resonance imaging is optional. ° ‘Type I - Osteochondral Reaction Exostosis X-rays manifest osseous spur formation greater than 3mm in size. No talar spur is present. Dorsiflexion stress x-rays show impingement and MRI is confirmatory for moderate osteoblastic and chondral hyperblastic reaction. ‘Type ILI - Significant Exostosis With or without fragmentation. Secondary spur formation seen on the dorsum of the talus, often with fragmentation of osteophytes, ‘Type IV - Pantalocrural Arthritic Destruction X-rays suggest medial, lateral or posterior degenerative, arthritic changes. ‘Treatment Conservative: rest, ¥ inch heel lift, prescription or nonprescription NSAIDs, and at least one intra-articular injection of 1% xylocaine and 40 mg of steroid. ‘Surgical: after conservative treatment fails, ankle arthrotomy or ankle arthroscopy may be performed. McDermott and Scranton compared the two procedures in their study and found that arthroscopy provided a quicker return to activity and reduced hospitalization time, especially in patients with type I, II, or III injuries. Some of the patients with type IV lesions were not candidates for arthroscopy techniques. Note: 45% of football players and 59% of dancers have this disorder 40G. Grant Ottawa Rules Stiell IG, Greenberg GH, McKnight RD, et al: Decision rules for the use of radiography in acute ankle injuries, JAMA 269(9):1127, 1993, Quick facts: 1. The Ottawa rules are not a classification system, they are a set of criteria the hospital may or may not follow to determine if scout ankle and foot x-rays are indicated, They are not yet considered the standard of care, and therefore should 7iot supercede your clinical judgement. 2. The study was done in an effort to reduce costs. Due to the large number of ankle films that were taken exhibiting no fracture, these criteria were developed and modified so that needless time and film was not wasted. 3. With the modified rules as outlined, there was 100% sensitivity with ankle fractures and 98% sensitivity with foot fractures in 1485 patients. ‘are xay san ony recessary A lot ay stn ony naconsry tor npainonarhe malo ard ay ot Dore span he ciel an tase tear Bose tgs! covet 1 nai bear wag oh ‘ty arab nage ‘sree ‘Separator sop) pane spe) 2. Bone tren tha 2 Bono tne a ona fe oripof bar males orb tas beth mare, ‘ Lar Mod ated Moda ArC. Ananian Lateral Ankle Ligamentous Injuries: Donoghue; Dias; Leach; Henry > O'Donoghue O'Donoghue DH: Treatment of ankle injuries. Northwest Med 57:1277, 1958, Grade Clinical Presentation Grade I Mild tendemess Partial tear of ligament © Mild swelling © Slight/no functional loss (WB/ambulate w/minimal pain) + No mechanical instability (negative stress exam) Grade IT © Moderate pain Incomplete tear of ligament | © Moderate swelling with moderate functional * Mild/moderate ecchymosis & tenderness over involved impairment structures Some loss of motion/function (pain on WB & ambulation) Mild to moderate instability (mild positivity in clinical stress exam) Grade OT © Severe swelling (> 4 cm diameter about the fibula) Complete tear with loss of | © Severe ecchymosis ligament integrity © Loss of function/motion (unable to bear weight/ambulate) ‘* Mechanical instability (moderate to severe positivity in stress exam) > Dias Dias, LS: The lateral ankle sprain: an experimental study. J Trauma 19:26, 1979. Grade I: Partial rupture of the calcaneofibular ligament (CFL) Grade II: Complete rupture of the anterior talofibular ligament (ATFL) Grade IM: Complete rupture of the ATFL, CFL, and/or posterior talofibular ligament Grade IV: — Complete rupture of all three lateral collateral ligaments and partial failure of the deltoid ligament 48> Leach Leach, RE: Acute ankle sprain : treat vigorously for best results. J Musculoskeletal Med 83:68f, 1983, 1 degree sprain: Rupture of the ATFL 2" degree sprain: Rupture of the ATFL & CFL 3" degree sprain: Rupture of the ATFL, CFL, and posterior talofibular ligaments. > Henry (source not found) GroupI: __- tenderness over ATFL ~ negative anterior drawer test ~ talar tilt <5 degrees Group II: - moderate injury ~ tenderness over ATFL & CFL ~ negative anterior drawer test - talar tilt < 5 degrees Group III: — - severe injury - lateral ankle swelling & pain ~ positive anterior drawer test -talar tilt > 5 degrees Group IV: _ - chronic problem ~ positive anterior drawer test ~talar tilt> 5 degrees Diagnostic Procedures Schuberth JM, et al, ACFAS Preferred Practice Guidelines, October 1996. X-Ray Scout films: AP Ankle, Lateral Ankle, Mortise Ankle, AP foot Inversion Stress (talar tilt); 5 degree increase in talar tilt indicates loss of CFL integrity when compared with contralateral ankle Anterior Drawer Sign: 4 mm increase in anterior displacement of the talus indicates a loss of integrity of the ATFL “Always evaluate uninjured foot for lack of symmetry” 49Treatment of Acute Injury ‘Schuberth JM, et al, ACFAS Preferred Practice Guidelines. October 1996 RICE. GradeI: 12 to 48 brs. Grade I: 12 to 72 hrs. Grade Il: 1 to7 days Immobilization Grade I: _ usually unnecessary Grade II: 2 to 6 weeks Grade III: 3 to 6 weeks* (surgery may be indicated) Splinting/Bracs Grade I: usually unnecessary Grade TI: 1 to 4 weeks Grade II: 1 to 6 months Physical Therapy Grade I: Not required Grade I: 2 to 6 weeks Grade III: 4 to 8 weeks ‘Total Duration of Management Grade I: 1 to 3 weeks Grade II: 3 to 12 weeks Grade III: 2 to 6 monthsJ. Jansma Anterior/Posterior Inferior Tibiofibular Ligament Avulsion Fractures Mandracchia DM, Mandracchia VJ, Buddecke Jr. DE: Malleolar fractures of the ankle. A comprehensive review. Clin Pod Med Surg 16(4):679, 1999. The syndesmosis is the most significant ligamentous complex of the ankle uniting the distal tibia and fibula. Three distinct ligaments form this complex: the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the tibiofibular interosseous membrane. Specific avulsion fractures classified with ankle injuries: ‘Tillaux-Chaput: Chaput’s tubercle is the anterolateral tubercle of the tibia and one of the insertion points for the AITFL. Mechanism: Lauge-Hansen SER-I, PAB-II, PER-I The Tillaux fracture is a subtype of Salter-Harris III classification of epiphyseal fractures, described as an isolated fracture of the lateral distal tibial epiphysis avulsed by the anterior tibiofibular ligament, (Kennedy MA, et al: The Tillaux Fracture: A Case Report, J Emerg Med 16(4):603, 1998.) ‘Wagstaffe: Wagstaff’s tubercle is the anterior portion of the lateral malleolus and the other insertion site of the AITFL. Mechanism: Lauge-Hansen SER-I, PAB-I, PER-I Volkmann: Volkmann's tubercle is the posterior lip of the tibia and the attachment site of the PITEL. The posterior lip is commonly referred to as the third or posterior malleolus. Mechanism: Lauge-Hansen SER-III, PER-IV SiC. Jacka Ankle Diastasis Without Fracture: Edwards & DeLee Edwards GS, DeLee JC: Ankle diastasis without fracture, Foot Ankle 4: 305, 1984, Clinical: tenderness over deltoid & anterior syndesmosis ligaments; pain worse with AJ dorsiflexion, pain with tibia-fibula squeeze @ midshaft (+ Hopkinson), & pain with external rotation stress with knee @ 90° (+ Kleiger test). + Stress radiographs showing < Imm widening of ankle mortise ~ stable AJ sprain Latent Diastasis ~ Routine radiographs look normal, r/o Maisonneuve fx. ~ Stress radiograph w/ abduction or external rotation force shows >Imm widening of mortise compared to normal side. - Rupture of Deltoid & AITF ligaments. ‘Tx immobilization with diastasis reduced x6 wks Frank Diastasis ~ Diastasis readily visible on routine radiograph ~ 1/0 Maisonneuve fx & proximal tibiofibular dislocation - Stress views unnecessary - Deltoid & AITF ligaments ruptured Typel -MO ankle view shows straight lateral subluxation of fibula w/ widened mortise + LAT ankle view to r/o posterior subluxation of fibula ~ Clinical: mediolateral motion of talus; tenderness @ medial & anterior aspects of AJ Tx: ORIF, remove interposed soft tissue, use tibiofibular screw to stabilize syndesmosis; BK cast x 6 wks followed by screw removal, aggressive ROM, strengthening exercises, & WB ‘Type - Plastic deformation of fibula with widened AJ mortise - Distinguish from type I @ time of surgery by absence of soft tissue interposition and fibula cannot be reduced ‘Tx: ORIF with fibular osteotomy to reduce mortise; tibiofibular screw to stabilize syndesmosis. Post-op: same as above Type 11 - Posterior rotatory subluxation of distal fibula; fibula is trapped behind tibia ~ Clinical: decreased distance between fibula & Achilles Tx: closed reduction and plaster immobilization s2Type IV - Talus is dislocated superiorly, wedged between tibia and Abul la ‘Tx: closed reduction and plaster immobilization $3F. Nejad Maisonneuve Fracture: Pankovich Pankovich AM: Maisonneuve Fracture of the Fibula. J Bone Joint Surg 58A(3):337, 1976. An external rotation force produces an oblique fracture of the lateral malleolus if the anterior tibiofibular ligament is adequate to resist the stress, or, if the ligament ruptures, there is a Sracture of the proximal third of the fibula, known as the Maisonneuve fracture. Stage I: Tendemess, swelling and ecchymosis seen at anterior aspect of syndesmosis Stage II: Tendemess in anterior aspect of syndesmosis, Undisplaced fracture of posterior tubercle of tibia (Volkmann's process) Stage III: Stage I & II plus: Possible rupture of anteromedial part of capsule Tendemess and swelling over anteromedial capsule Stage IV: Stage I-III plus: ‘High fibular fracture from pronation external rotation > supination external rotation Possible rupture of ATF and interosseus ligaments Stage V: Definitive rupture of ATF, interosseus ligaments, and anteromedial capsule Deltoid ligament rupture or medial malleolus fracture (Note: all proximal fibula fractures were from pronation external rotation) ‘Note: All Maisonneuve ankle fractures are caused by external rotation of the foot in relation to the tibia, but its unclear whether the foot is in supination or pronation. 54F. Nejad Bosworth Fracture: Perry Perry CR, Rice R, Rao A, Burdge R: Posterior fracture-dislocation of the distal part of the fibula. J Bone Joint Surg 65A(8):1149, 1983, The Bosworth fracture, a fixed posterior fracture-dislocation of the distal part of the Sibula due to external rotation of the supinated foot, is a rare injury. The initial stages of the injury are identical to those of the Maisonneuve fracture. The final stages unique to this fracture-dislocation are the posterior dislocation and fracture of the fibula and the Jracture of the medial malleolus or rupture of the deltoid ligament. The objectives of ‘treatment are open reduction of the dislocation, repair and stabilization of the biofibular syndesmosis, and restoration of the ankle mortise to its anatomical position. Stage 1: Rupture of the Anterior Inferior Tibiofibular Ligament (AITFL) or avulsion of one of its attachments Stage 2: Rupture of the Posterior Inferior Tibiofibular Ligament (PITFL) or avulsion of one of its attachments Stage 3: Rupture of the anteromedial part of the capsule Stage 4: Tear of the interosseus membrane Stage 5: Posterior entrapment of the fibula behind the tibia Stage 6: Fracture of the fibula Stage 7: Fracture of the medial malleolus or rupture of the deltoid ligament 5SG. Grant Ankle Fractures: Danis-Weber; Lauge-Hansen > Danis-Weber Weber BG: Die Verletzungen des Oberen Sprungelenkes. Verlag hans Huber, Bera, 1972. Translated title: The Injuries of the Ankle. This classification is used by the Swiss AO group. It is based solely on the fracture of the lateral malleolus. A fundamental understanding of the Lauge-Hansen classification is required to appreciate this system. Type A Fracture line below the level of the inferior tibial-fibular syndesmosis. © fracture line > Supination Adduction (SAD) mechanism. sap Type B Fracture line at the level of the inferior tibial-fibular syndesmosis. « straight oblique fracture line ~» Pronation Abduction (PAB) mechanism. as vas V _¢ spiral oblique fracture line => Supination External Rotation (SER) mechanism. ‘Type C Fracture line above the level of the inferior tibial-fibular syndesmosis. « straight oblique fracture line ~» Pronation Dorsiflexion mechanism. ver Y © spiral oblique fracture line +» Pronation External Rotation (PER) mechanism. ‘Treatment Considerations 1. Increasing the mechanism of injury, distracting the limb, and then reversing the mechanism of injury is the method by which anatomic reduction is generally achieved. "2. Reestablishing the length and position of the lateral malleolus is the most critical element of Proper management. If the fibular malleolus displaces superior and posterior to the point where closed reduction can not achieve anatomic parameters, ORIF is indicated, Tension band wiring may be used to provide compression, or screw fixation via lag technique with 4.0 mm cancellous screws. The fibula may also be fixated with 3.5 mm coritical screws if desired. A — tubular plate is often used on the fibula, especially in osteopenic bone, sometimes in an anti-glide position. 2 screws are placed both above and below the fracture. . 2 syndesmotic screws used to correct diastasis should engage a minimum of 3 cortices in a non-lag fashion (3-point technique) Altematively, 1 screw that engages 4 cortices may be used (4-point technique). The screw is usually set 3-5 em proximal to the AJ. s> Lauge-Hansen Lange-Hansen, N: Fractures of the Ankle: analytic historic survey as the basis of new experimental, roentgenologic, and clinical investigations. Arch Surg 56:259, 1948, Lauge-Hansen is the last name of one physician from Denmark. Several articles were written about the system and originally included only 4 mechanisms. The classification is based on both experimental cadaveric studies and clinical experience in fractures commonly seen. It is Perhaps the most widely used system for ankle fractures. Concepts . ‘The first term describes the position of the foot atthe time of injury, the second term describes the direction of pathologic force on the talus direction the talus moves relative to the leg, although because the foot is typically fixed the tibia actually moves relative to the talus). * The classification is staged according to a sequential pattem of injury: ifthe fracture is stage 3 then stages 1 and 2 also had to occur with their associated soft tissue & osseous damage. * Consider the fractures as clockwork patterns for the rotational injuries and direct blows patterns across the ankle for the abduction and adduction injuries. a Injury Clarification + SER-Iis the most common injury while PER is the most destructive. + Always verify the stage and mechanism of injury by looking for manifestations of the next Stage to ensure it has not occurred (check the posterior lip of tibia, high fibula, ete.) and Temember the soft tissue injuries that accompany each fracture mechanism, * PAB-I could also be a PER‘L If, or I ~*ankle mortise and high fibular films are necessary to rule out associated injuries (diastasis, Maisonneuve fracture) * In the absence of additional stages of osseous injury, SER-II and PAB-III must be differentiated by the appearance of the fibular fracture line + SER IL, SAD I, PAB J, PER II without fractures are simply ankle sprains, Note: Items appearing in bold (in each stage below) represent osseous injuries and are therefore found on radiographic examination. Supination-Adduction — SAD (direct blow injury) SAD-I: Straight transverse fracture of lateral malleolus at or below level of the AJ or rupture of the lateral collateral ligaments SAD-II: Oblique fracture of the medial malleolus (directed inferolateral-superomedial) pet STAGE ISupination-Eversion [External Rotation] — SER (clockwork injury) SER-I: Rupture of anterior inferior tibiofibular ligament (AITFL) or Tillaux-Chaput (tibia) / Wagstaffe (fibula) avulsion fracture SER-II: Spiral oblique fracture of lateral malleolus at level of the AJ (posterior spike on LAT x-ray) SER-III: Rupture of the posterior inferior tibiofibular ligament (PITFL) or Posterior tibial lip (malleolus) fracture - small fragment (Volkmann’s) SER-IV: Straight transverse fracture of medial malleolus or rupture of the deltoid ligament STAGE I Pronation-Abduction ~ PAB (direct blow injury) PAB-I: Straight transverse fracture of medial malleolus or rupture of the deltoid ligament PABLI: Rupture of the both the anterior and posterior tibiofibular ligaments (without diastasis) PAB-I: Straight oblique fracture of the lateral malleolus at the level of the AJ (directed inferomedial-superior lateral — lateral spike on AP x-ray)Pronation-Eversion [External Rotation] ~ PER (clockwork injury) PER-I: Straight transverse fracture of medial malleolus or rupture of deltoid ligament AITFL rupture with tear of tibiofibular interosseous membrane (diastasis) or Tillaux-Chaput/ Wagstaff fracture fragment (much less common) PER-III: Spiral oblique fracture of the fibula above level of AJ (posterior spike) (fracture begins at the level where interosseous membrane rupture stops) PER-IV: Posterior tibial lip (malleolus) fracture - large fragment (Volkmann’s) or rupture of the PITFL, stage mr ‘STAGE IF Pronation-Dorsiflexion [Pilon Fx] (clock work injury) Stage I: Straight oblique fracture of the medial malleolus Stage II: Fracture of the anterior lip of the tibia large fragment Stage III: Straight oblique or transverse fracture of fibula above the level of AJ Stage IV: Relatively transverse fracture of the posterior tibia often at the level of the proximal segment of the anterior fracture line. 54D. Clement Pilon Fractures: Reudi-Allgower; AO; Ovadia-Beals; Lauge-Hansen; Kellam-Waddell Pilon = intra-articular distal tibial metaphysis. Mechanism This is a high impact injury. The most common mechanism is axial compression. ‘The talar dome is driven into the ankle mortise with a resulting crush injury of the pilon and probable damage to the talar dome. A less common mechanism is a rotational mechanism with the foot ronated and dorsiflexed. Thus there are two types of classifications: those that classify axial compression injuries (more common) and those that classify rotational injuries (less common). Repair 1. Restore the length of the fibula. 2. Reconstruct the tibial articulation using the “key” fragment and talus as a template. 3. Fill in defects with cancellous bone graft. 4. Apply buttress plate fo the medial tibia to prevent late tibial varum deformity. Axial Compression Classifications > Ruedi-Aligower + most commonly used classification Type: Cleavage fracture of the distal tibia without major dislocation of the articular surface, ‘Type I: Significant fracture and dislocation of the joint surface without comminution, ‘Type III: Impaction and comminution of the distal tibia, Clin Orthop Rel Res 138:105, 1979 > AO-ASIF + The AO group adopted the Ruedi-Allgower system, set it to the ABCs, and further classified articular fracture patterns ‘Type A: intra-articular fracture without major incongruency - Ruedi-Allgower Type I. AL: metaphyseal simple fx 2: metaphyseal wedge fx A3: metaphyseal complex fx Type B: intra-articular fracture with significant incongrueny - Ruedi-Allgower Type II. B1: pure split fx B2: split-depression fx BS: multifragment depression fx lo‘Type C: intra-articular fracture with displacement - Ruedi-Allgower Type II. C1: articular simple, metaphyseal simple fx C2: articular simple, metaphyseal multifragment fx C3: multifragmentary fx > Ovadia-Beals ‘© most recent system, but it will not likely replace Ruedi-Allgower/AO-ASIF anytime soon. ‘Non-displaced articular fracture. Minimally displaced articular fracture. Displaced articular fracture with several large fragments. Displaced articular fracture with multiple fragments and large metaphyseal defect. Displaced articular fracture with severe commimution, J Bone Joint Surg Am 68(4):543, 1986 Rotational Classifications > Lauge-Hansen: Pronation-Dorsiflexion * this system is sequential like the other Lauge-Hansen mechanisms of injury Stagel: fracture of the medial malleolus. Stage II: Stage I plus fracture of the anterior lip of the tibia (large fragment). Stage III: Stage II plus fracture of the supramalleolar part of the fibula. Stage IV: Stage III plus fracture of the posterior tibia, typically at the same level as the proximal segment of the anterior fracture line. Arch Surg 56:259, 1948 > Kellam-Waddell * this system is based on the presence or absence of rotatory forces. ‘Type A: Fractures with more rotatory than axial compression forces. There are typically 2 or more large, intraarticular tibial fragments, with a transverse or short oblique fibular fracture above the level of the tibial plafond. They are less common and carry a poorer prognosis than Type B. ‘Type B: Axial compression fractures without rotatory forces. There is marked anterior tibial cortical comminution, multiple tibial fracture fragments, superior migration of the talus, and narrowing of the ankle joint. They are more common and carry a better prognosis than Type A. I Trauma 19(8):593, 1979 61Ruedi-Allgower Classification: The “key” fragment follows the fibula on injury; therefore itis the first tibial fragment to be put into place after restoration of the correct length of the fibula. 62Seattle Style - Telos Local anesthetic: nesicaine (shortest half-life — lasts only 30-40 minutes) Block common peroneal nerve - down to fibula, then back up a bit ~ ask patient about sensation: shocks or waterfall feeling Comparison views (B/L films) Measurements: Anterior Drawer — use % to allow for varience in tibial plafond Measure anterior-posterior tibial plafond, dome of talus, and connect dots Compare arc of circles: plafond center vs. talar dome center (plafond + dome) 5% greater than contralateral side or 18% absolute difference (if paony Talar tilt 5% greater than contralateral side or 10% absolute IC, ty Com 6) hawe BIL! 0-5 mmm soll Fb em raphee Hebiwar — Met: > Ym repre Ch Sm hw of Ke Md it randD. Collman Epiphyseal Fractures: Salter-Harris; Odgen; Rang Salter RB, Harris RW: Injuries involving the epiphyseal plate. J Bone Joint Surg 45-A:587, 1963. Odgen JA: Injury to the growth mechanisms of the immature skeleton. Skeletal Radiology 6:237, 1981. Odgen JA. Children’s Fractures, 2" Ed. Lea & Febiger: Philadelphia, 1983. Rang M. The Growth Plate and Its Disorders, 2™ Ed. Churchill-Livingstone: London, 1983. The classification system proposed by Salter and Harris is the most widely accepted, though the modifications by Odgen further clarify physeal injury mechanisms and prognosis. The presented system combines both systems, along with Rang’s addition, as described in McGlamry's text. Physeal injuries comprise approximately 10% of all pediatric fractures (4.4% tibiaffibula, 5.9% foot), are more common during the first year and puberty, and more frequent in boys. Concepts + Physis = radiolucent cartilaginous growth plate « Injury prognosis determined by disturbance of physeal blood supply (based on fracture type) ‘Good: physis separation from metaphysis Poor: fracture crosses physis Worse: fracture crosses physis completely covered by articular cartilage + Types I & I: extra-articular fx, best prognosis + Types II] & IV: intra-articular, poor prognosis unless physis & congruent joint surface restored + If blood supply undisturbed, fracture will heal in 3 weeks « Physis is weaker than bone, tendon, ligaments, joint capsule + Force mechanisms of injury: shear, avulsion, bending, axial compression. + High index of suspicion in joint sprain, dislocation, long bone involvement + Always attempt to determine the mechanism of injury — key aid for diagnosis + Indirect trauma most common mechanism of ankle injury in children + Age and force determines patter of ankle fracture: + types I & Il - shear force — younger children + types III & IV — bending/compression force - older children Ossification of Physis + Prior to the appearance of secondary ossification center, the diagnosis must be made ‘on the basis of injury mechanism, metaphyseal displacement, and soft tissue swelling «+ Distal tibia epiphysis appears at 2 years, fuses 17-19 years (begins centrally, proceeds medially lateral portion closes 18 months later) + Distal fibula epiphysis appears at 2 years, fuses at 11-14 years + Metatarsal epiphysis appears at 2-3 years, fuses at 15-18 years + Calcaneal apophysis appears at 5-12 years, fuses at 15-20 years 63‘Treatment: ‘children have textbook anatomy, heal well, and are honest about pain’ - Dr. Bums + BIL scout x-rays essential + gentle manipulation critical (avoid prying with instruments) + do not curette fracture surfaces — pluse lavage only + reduce fracture within 7-10 days before consolidation occurs Tywesl&I: — closed reduction ‘Types MIL IV, V: ORIF — restoration of joint congruency is essential; do not compress physis + Smooth K-wires may cross physis if no more than 7% of physis is destroyed + Opening wedge osteotomies may be indicated if varus/valgus deformity persists + Fixation must always be removed ‘Type I: complete separation of epiphysis from metaphysis i t ‘ shear or avulsion force, no fracture «growing cells remain with physis, undisturbed ‘+ miminal displacement b/c of thick periosteum (facilitates reduction) + radiographic dx often difficult — rely on clinical symptoms and exam + excellent prognosis (except Type IC) TA: complete separation of epiphysis from metaphysis between layers of chondrocyte hypertrophy and calcification IB: separation through layer of degenerative cartilage IC: crush injury damaging one side of physis, premature osseous bridge may result secondary to cell damage ‘Type Ii: fracture line through physis, exiting out metaphysis ‘© most common acute physeal injury + shear or avulsion force « triangular-shaped metaphyseal fragment: Thurston-Holland’s Sign + Periosteal hinge facilitates reduction children > 10 years «prognosis good if physeal vessels intact, TIA: Metaphyseal fragment attached to epiphysis, periosteum intact on concave side of fracture but tom on convex side IIB: Metaphyseal fragment is free, periosteum torn both sides TIC: Thin layer of metaphysis present across physeal fragment (most common in phalanges b/c transverse trabeculae) ID: Compression against physis at point fracture exits metaphysis : , Type III: fracture from articular surface to weak zone of physis and along plate to the periphery + bending/compressive force (some shear force) ‘© more common in older children + accurate reduction essential to restore congruity of tibial plafond + pronosis good if physeal vessels intact TITA:as described by type I LIB: small layer of growing cells avulsed with epiphysis, oFa Type IV: fracture from articular surface through epiphysis, across physeal plate, and exits through metaphysis + bending/compressive force * more common in older children + accurate reduction essential to restore physeal function and congruent articular surface (prevent arthroses/growth arrest) + prognosis poor unless physis and joint restored IVA: as described by type IV IYB-IVD: involve multiple fragments of epiphysis/metaphysis ‘Type V: severe crushing force through epiphysis, destroys a portion of or the entire physis «relatively uncommon + etiology may be non-traumatic — osteomyelitis, aseptic necrosis ++ requires high index of suspicion (often misdiagnosed): ° no visible fracture, physeal displacement unusual + may exist with another type and go unrecognized © poor prognosis: premature plate closure typically results ‘Type VI:_avulsion of perichondral ring (physeal periphery) ‘* modification by Rang + no evidence of fracture at injury + caused by blunt trauma such as bums or degloving injuries that disturb the physeal periphery + formation of peripheral osseous bridge after injury + angular deformity develops gradually ‘Type VII: epiphyseal fragment avulsion fracture without physis * no physeal involvement (not part of original system) rare + no disturbance of growth, excellent prognosis GSModified Dias-Tachdijan Classification System for Pediatric Ankle Fractures ‘Schuberth JM, DeValentine SJ: ‘Ankle injuries’ in DeValentine SJ (ed): Foot and Ankle Disorders in Children. Churchill Livingston, New York, 1992. we 5 ies ‘Supination-Inversion ‘Supination-Plantar Flexion Pronation-Eversion- ‘Supination-External External Rotation Rotation Isolated External ‘Axial Compressio Rotation ee AS Juvenile Tilaux Triplane FractureK. Van Voris Tarsal Coalitions: Articular Classification System Downey MS: Tarsal Coalitions: A surgical classification. J Am Pod Med Assoc 81(4):87, 1991. Etiologic classification = Congenital: Leboucq’s theory suggests that tarsal coalition results from the failure of the differentiation and segmentation of primitive mesenchyme. Leonard concluded that tarsal coalitition was a unifactorial inheritance, allowing this theory to be the most widely accepted. = Acquired: Articular classification disorder with autosomal dominant tarsal coalition can result from arthritis, infection, trauma, neoplasms, and is most commonly seen in the older patient. This system suggests that the most important criteria for determining surgical treatment are the patient's age, the articular involvement or the relationship of the bones forming the coalition, and the degree of secondary arthritic changes in joints around the coalition. STEP 1: Division of tarsal coalitions into extra- and intra-articular. Extra-articular Coalitions Calcaneonavicular Cubonavicular Intra-articular Coalitions Talocalcaneal Middle Posterior ‘Naviculocuneiform *Multiple and massive coalitions are considered intra-articular Gt STEP 2: Articular Classification Svstem Suvenile (Osseus Immaturity) Type I: Extra-articular coalition A-No secondary arthritis B- Secondary arthritis Type I: Intra-articular coalition ‘A- No secondary arthritis B- Secondary arthritis Adult (Osseous Maturity) Type I: Extra-articular coalition ‘A- No secondary arthritis B- Secondary arthritis Type I: Intra-articular coalition ‘A- No secondary arthritis B- Secondary arthritisSTEP3 Possible surgical procedures based on the Articular Classification System. The procedures in boldface are the most common Juvenile IA Resection with interposition of extensor digitorum brevis muscle Resection with interposition of acipose issue Resection with varus-produong calcaneal osteotomy Resection with insenion of enplant \Varus-producing calcaneal osteotomy alone Juvenile 1B Resection with interposition of extensor digitorum ‘brevis muscle RResuction with interposition of aipose tissue Resection with varus-produsing calcaneal osteotomy Resection with insertion of implant Varus-producing calcaneal osteotomy alone ‘Triple arthrodesis Juvenile 1A, Resection alone Resection with interposition of adipose tissue Resection with interposition of arthroereisis Resection with varus-producing calcaneal osteotomy Varus-producing calcaneal osteotomy alone Isolated/single arthrodesis, ‘Triple arthrodesis oy overt 1B ‘Triple arthrodesis ‘Adult A Resection with interposition of extensor digitorum brevis muscle Resection with interpositon of adipose tissue Resection with varus-producing calcaneal osteotomy Resection with insertion of plant Varus-producing calcaneal osteotomy alone Triple arthrodesis Aut 1B Resection with isolated/single arthrodesis ‘Triple arthrodesis Adult WA Isolated) ingle arthrodesis,K, Van Voris STJ Dislocation: Buckingham Buckingham WW: Subtalar dislocation of the foot. J Trauma 13(9): 753. Also known as: luxatio pedis subtalo; subastragalar dislocation; and peritalar dislocation. Medial STJ Dislocation (most common): “basketball foot” or “acquired clubfoot” Mechanism During forceful inversion of the foot the sustentaculum acts as a fulcrum for the posterior part of the talar body, producing dislocation 1®- dislocation of the TN joint fae = rotary subluxation of TC joint causing calcaneus to move medially under the talus PI Incomplete dislocation: the head of the talus is palpable on the dorsum of the foot between the EHL and the EDL tendons Complete dislocation: calcaneus is displaced medially in relationship to the leg *Skin overlying the talar head will appear blanched and tight, the medial border of the foot appears shortened and the lateral border lengthened, the digits may appear dorsiflexed, the tibial malleolus may not visible, and the lateral talar process is easily palpable. Lateral foot: talar head is superior to the navicular AP foot: medially displaced navicular to the talus, negative Kite’s angle, nonarticular TN joint ‘AP ankle: foot displaced medially through the STJ with the tarsus intact in the ankle mortise *The presence inversion-type ankle fracture patterns should be looked for Closed. Closed Reduction “Apply countertraction to the flexed thigh to relax the gastrocnemius "Reduce the TC joint by forced inversion while distal traction force is maintained = Reduce the TN joint by applying downward pressure on the talar head while the foot is plantarflexed * Dorsiflex the and pronate the STJ and MTS about the talus, relocating the head of the talus with the navicular = BK WB cast 6 weeks > Obstacles preventing closed reduction: 1. Impaction of the navicular with the talar head 2. Talar head button-holing of the extensor retinaculum or the EDB muscle belly 3. Peroneal tendons about the talar head Lateral STJ Dislocation Mechanism During forceful eversion of the foot, the anterior process of the calcaneus acts as a fulcrum for the anterolateral corner of the talus 1" - forcing the talar head through the TN capsule medially ats dislocating the calcaneus laterally beneath the talus and the leg 69Physical Exam ‘Incomplete dislocation: the talar head is palpable over the medial aspect of the foot Complete dislocation: the calcaneus is displaced laterally *The lateral border appears shortened while the medial border appears lengthened, the digits appear plantarflexed due to the stretch of tarsal canal structures, and the fibular malleolus is not visible laterally Radiography ‘AP foot: the navicular is displaced laterally from the head of the talus and the calcaneus is dislocated laterally Lateral foot: overlap of tarsal bones without demonstratable STJ *associated more with fractures seen in a forced eversion ankle sprain Closed reduction * Should be done under general spinal anesthesia or IV muscle relaxants = Apply distal traction to the calcaneus about a flexed knee = Reduce the TC joint by forced eversion while distal traction force is maintained = Reduce the TN joint by applying downward pressure on the talar head while the foot is plantarflexed = Dorsiflex the and pronate the STJ and MTJ about the talus, relocating the head of the talus with the navicular = BK WB cast 6 weeks > Obstacles preventing closed reduction: 1. Impaction of the navicular with the talar head 2. Talar head button-holing of the extensor retinaculum, 3. Tibialis Posterior tendon 4, Long flexor tendon Posterior STJ Dislocations (rare) Mechanism Result from falls from a height on an outstretched foot in a plantarflexed position Physical Exam ‘The forefoot appears shortened, with the heel protrudes posteriorly, and the longitudinal axis, of the foot appears normal. Closed Reduction Under general anesthesia, disengage the dislocation with heel traction = Dorsiflex the foot on the talus » Anterior STJ Dislocation : Results from a fall ftom a height onto a dorsiflexed foot position Physical Exam ‘The foot appears lengthened longitudinally with a flattened heel Closed reduction = Under general anesthesia the foot is distracted distally with heel traction = Direct the foot forcefully backward under the talus JoJ. Jansma STJ Arthroereisis: Volger; Green-Grice; MBA Arthroereisis is the ‘operative limiting’ of excessive motion in a joint. Arthroereisis of the subtalar joint was first performed by Chambers in the effort to limit pronation, Since then, multiple devices and procedures have been devised to aid in the correction of the flexible flatfoot. The specific arthroereisis procedure chosen is based mainly on the plane of the deformity and the ability of the midtarsal joint to lock. A high subtalar joint axis will yield more motion in the transverse plane, while a low subtalar joint axis will produce more motion in the frontal plane. >Volger — based on function Yu GV, Boberg J: Subtalar Arthroeresis. In McGlamry ED (ed): Comprehensive Textbook of Foot Surgery. Williams & Wilkins: Baltimore, 1992. Ist category: self-locking wedges, inserted into the sinus tarsi that restrict the end range of motion of the STJ to neutral or a varus position. Mechanism is to prevent the lateral process of the talus from contacting the floor of the sinus tarsi (best results with adolescent and adult patients). Examples: Addante; Villadot umbrella. 2nd category: axis-altering prostheses that raises the STJ axis, limiting the motion in the frontal plane (procedure reserved mostly for the pediatric patient). Example: STA-peg. 3rd category: impact-blocking devices that limit valgus motion by the impingement effect. The lateral process of the talus contacts the prosthetic device, therefore stopping motion (procedure done in all ages). Examples: Valente; MBA. Indications: flexible pes valgus deformity Indications with combination of a soft tissue and osseous procedure: paralytic or spastic pes valgus, tarsal coalition, posterior tibialis dysfunction Contraindications: rigid pes valgus deformity, significant arthritis, severe frontal plane abnormalities, equinus, skewfoot deformity, age and morbid obesity ‘+ Implants that alter the axis (Volger type I1), should be removed once functional adaptations of the talus and calcaneus have occurred. «= Implants that are self-locking wedges or implant blocking devices (Volger type I or III) are permanent, unless they become problematic. 4> Green-Grice ~ extraarticular STJ arthrodesis (HASTA) Lancaster SJ, Pohl RO: Green-Grice extraarticular subtalar arthrodesis: results using a fibular graft. J Pediatr Orthop 7(1):29, 1987. ‘The procedure consists of bone graft ~ a fibular strut — inserted into the sinus tarsi abutting the calcaneus and the talar neck, effectively fusing the subtalar joint. The graft must be parallel to the longitudinal axis of the tibia with the ankle at 0 degrees dorsiflexion. Indications: ambulatory patients with progressive, mobile, planovalgus deformit abnormal medial weight-bearing Contraindications: fixed bony deformity > Maxwell-Brancheau Arthroereisis (MBA) ‘Maxwell JR, Carro A, Sun C: Use of the Maxwell-Brancheau Arthroereisis implant for the correction of posterior tibial tendon dysfunction: Clin Pod Med Surg 16(3):453, 1999, ‘The MBA is a threaded, titanium, self-locking implant. Advantages: simplicity, predictability, low incidence of failure, accurate visualization for placement, extra-articular nature Contraindications: rigid deformity, flatfoot deformity with no calcaneal eversion, significant arthritis, ankle valgus deformity, and prior infection 2D. Colman Tibialis Posterior Tendon Dysfunction: Johnson & Strom; Conti; Funk Tibialis Posterior — prime RF stabilizer: RF inverter to lock MTJ, anti-pronator, lies posterior to AJ axis and medial to STJ axis > Johnson & Strom - clinical/radiographie classification Johnson KA, Strom DE: Tibialis posterior tendon dysfunction. Clin Orthop 239: 196, 1989, Stage I — tendon length normal; peritendonitis and/or tendon degeneration Signs & Symptoms foot appears normal, minimal changes on x-ray gradual onset of pain along tendon course, palpable/focal pain just proximal to medial malleolus, pain increases with activity © fullness inferior to medial malleolus (appreciate from posterior view) + mobile/normal hindfoot alignment, normal FF to RF relationship © mild weakness on single heel-raise test (patient senses abnormality) Pathology synovial proliferation with possible degeneration © split tears in tendon, enlarged 2x width ‘Treatment ‘Conservative: break eycle of inflammation with 3-6 mos of rest, NSAIDs, orthoses [deep heel cup, 4-6 mm Kirby skive, medial phalange, inverted device; Richie brace] NOTE: monitor patient — should not progress to stage II or III with conservative care ‘© Surgical: synovectomy, tendon debridement, rest (BK cast 3 wks) Stage II — tendon elongated, hindfoot mobile Signs & Symptoms increase severity & distribution of pain, continues post-activity pain along tendon for moderate length fullness & tenderness inferior to medial malleolus (appreciate posteriorly) mobile/valgus RF; FF abduction (positive ‘too-many-toes’ sign) marked weakness on single heel-rise test ° Xaay AP foot: FF abduction, navicular subluxed off talar head, increased T-C angle LAT foot: T-N fault, increased talar declination angle © MRI: discontinuity and ‘balling up’ of tendon Pathology ‘© 2-3 em tendon degeneration, longitudinal tears, secondary adhesions to sheath ‘© yellowish white-brown appearance, firm consistency, off-white ‘fish-flesh’ proximally ‘© possible single transverse tear (rounded-off ends), ‘white-sign’ proximal to rupture site see B‘Treatment * FDL transfer, under tension, undersurface of navicular via drill hole; BK cast 6 wks + PT * proximal attachment of TP muscle to FDL debated « [alternatives and adjuncts (evaluate planar dominance): Kidner, Young, ST] arthroereisis, Evans, Dwyer, Koutsougianis, isolated arthrodesis] Stage III — tendon elongated, hindfoot deformed & stiff Signs & © fixed flatfoot * medial pain, more suggestive of DJD (b/c of activity-related sharp pain on rest), may transfer to lateral RF and over sinus tarsi b/c of lateral talar process impingement; NOTE: tendon itself is intrinsically less painful © fixed/valgus RF with significant eversion and ‘too-many-toes’ sign * marked weakness on single heel-rise test (may be impossible) °Xny Similar but more marked than stage Il — 2° degenerative changes at STJ, T-N, C-C jt Pathology ~ similar but more advanced than stage II ‘Treatment authors’ preference: realignment with STJ arthrodesis * [alternatives and adjuncts: isolated arthrodesis, Evans, Dwyer, Koutsougianis} *Stage IV — rigid hindfoot & valgus angulation of talus; early ankle joint degeneration *Myerson MS: Adult acquired flatfoot deformity. J Bone Joint Surg 78-A: 780, 1996. > Conti — MRI classification Conti S, Michelson J, Jahss M: Clinical Significance of Magnetic Resonance Imaging in Preoprative Planning for Reconstruction of Posterior Tibial Tendon Ruptures. Foot Ankle 13(4): 208, 1992, MRI grading of tendon pathlogy was shown to have prognostic value and serve as a better Predictor for clinical outcome after surgical treatment, superior to intraoperative tendon evaluation, which was found to have a limited role in determining tendon reconstruction. Type 1A fine longitudinal tendon splits without degeneration, often on tendon undersurface Clinical correlate: symptoms <6 mos, minimal swelling or tenderness, no RF valgus 4‘Type IB «multiple longitudinal tendon splits with mild fibrosis and increase width; no degeneration Clinical correlate: similar to Type IA but present for 6-12 mos Type « narrowed tendon with long longitudinal splits and degeneration, often bulbous appearance distal to attenuated portion Clinical correlate: symptoms 1-1.5 years with onset of increased RF valgus ‘Type IA ffuse tendon swelling, prominent uniform degeneration, and few intact tendon strands Clinical correlate: symptoms > 2 years with minimal inversion strength, marked RF valgus ‘Type HIB complete tendon rupture with replacement by scar tissue Clinical correlate: symptoms > 2.5 years with classic signs of rupture > Funk — surgical classification Funk DA, Cass JF, Johnson KA: Acquired adult flat foot secondary to posterior tibial-tendon pathology. J Bone Joint Surg 68-A: 95, 1986. This study examines the importance of intra-operative findings to qualify tibialis posterior tendon pathology and guide operative treatment accordingly, cautions against excessive emphasis on radiographic findings to predict pathology, and suggests that such pathology is not the only cause of adult acquired flat foot. Group I—avulsion of tendon from its navicular insertion ‘Sx treatment: reattach distal tendon to navicular via non-absorbable suture thorugh drill holes Group Il — complete mid-substance tendon rupture just distal to medial malleolus ” $x treatment: transfer/interposition of FDL tendon Group III - longitudinal tear without complete tendon rupture ‘Sx treatment: tendon debridement and synovectomy Group IV — synovitis without visible tear or disruption of tendon ‘Sx treatment: synovectomy and decompression (sheath release) eoB. Zarutsky Peroneal Tendon Dislocation: Eckert & Davis Eckert WR, Davis BA Jr.: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 58A:670, 1976. Oden RR: Tendon injuries about the ankle resulting from skiing. Clin Orthop 216:63, 1987. Grade: Superior peroneal retinaculum is ruptured from collagenous lip and lateral malleolus. ¢ > _The fibular periosteum is lifted/avulsed. The peroneal tendons can be anteriorly displaced over the lateral malleolus and after reduction, are unstable only with applied tension. Grade Ii: Distal 1-2cm of the dense fibrous lip on the posterior edge of the lateral malleolus is elevated along with the retinaculum, which is completely torn. Tendons are usually found over lateral malleolus and very unstable when reduced, ‘Tx: Same as Grade I Ta: Suture incised fascia to posterior margin of intact collagenous lip (remaining retinaculum) Grade IIL:A thin fragment of cortical bone with the collagenous lip is avulsed from the deep surface of the peroneal retinaculum. Tendons are always found over lateral malleolus and very unstable when reduced. X-rays are diagnostic (avulsion fx observed). ‘Tx: 2 K-wires inserted from posterolateral to anteromedial through the fracture fragment and fibula. Soft tissue repair is similar to Grades I and II. Grade IV: Avulsion of superficial peroneal retinaculum from posterior insertion on calcaneus (Oden °87) with anterior dislocation of tendons over the retinaculum. This is in contrast to grades I-IIl, where the superior peroneal retinaculum is separated from its fibular attachment. The tendons dissect through, with the retinaculum lying deep to dislocating peroneal tendons. ‘Dx: Primary repair of the retinaculum Fibug, ‘Treatment Guidelines ‘Surgical correction is required for all four grades due to the ineffectiveness of closed treatment. Post-operative management is immobilization in a short leg NWB cast x 3 weeks followed by 2-3 weeks in a walking cast. Acute Grade I and III injuries can NORMAL anatomy Potentially be successfully treated with 6 weeks short leg cast immobilization, however there is a high dislocation rate associated with this treatment option. 16G. hala Tendo-Achilles Radiopaque Lesions Morris, KL, Giacopelli, JA, Granoff, D: Classifications of radiopaque lesions of the tendo Achillis. Journal Foot Surg 29(6):533, 1990. Exostosis and extra-articular calcifications on or around the calcaneus are among the most common rearfoot procedures for podiatric physicians. Many of these radiopaque lesions manifest themselves in or around the Achilles tendon. Because numerous etiologic and Pathologic processes are responsible for their tendinous formation, the authors established this classification to help identify the specific etiologies associated with the anatomical, morphological, and pathological appearance of the lesions. intratendonous radioopacities at insertion or superior pole of calcaneus Location: Achilles tendon insertion site, either partially or totally attached to the calcaneus Radiography: involution of the lesion within the tendon fibers; osseous changes of the calcaneus (step deformity, exostosis, erosions) Pathology: heterotrophic or ectopic bone formation Etiology: inflammatory arthropathies, mechanical irritation leading to inflammation, Achilles tendonitis, calcaneal shape (termed “tendonitis ossificans traumatica” if caused by outgrowth of calcaneus) intratendoneous radiopacities at insertion zone; partial thickness Location: _ 0.5 to 3.cm proximal to Achilles insertion site. Radiography: lesions appear more dense and rounded than Type I lesions and do not commonly involve the entire thickness of the tendon Pathology: lesions are completely separated from calcaneus and are either linear or small ovoid fragments Conditions: articular chondrocaleinosis (ACC or pseudogout), idiopathic hemochromotosis, obesity, osteomyelitis, and vitamin Etiology: _embryogenic, osteogenic processes; inflammation w/secondary Crystalline deposition Type UII: intratendonous radioopacities proximal to insertion zone IIA: partially ossified Achilles tendon IIIB: totally ossified Achilles tendon nClinical: thickening of the tendon that can be asymptomatic or symptomatic, especially if fracture of the ossified tendon is present Location: 2 to 10 cm above the Achilles insertion site Radiography: lesions involve much greater tendon volume than Types I or II; X-rays, MRI, and CT useful for differentiating from xanthomas or tophi; transverse sonograms useful for measuring tendon thickness and planning surgical intervention Pathology: lesions contain lamellar, heterotrophic and calcified, spongy bone with central fibrous areas jology: trauma to the tendon from ruptures and surgical intervention, poor vascularity, idiopathic Treatment ‘Types 1 & IL Conservative: customized shoe modifications (softening, remodeling, or removing heel counters, heel lifts or shoe lowering, FFOs, heel cord stretching, ultrasound, hydrotherapy) Medications: NSAIDs, steroid injections (controversial). Requires gradual return to activity for 2-3 weeks post-injection therapy. ‘Surgical: _resection of the intratendinous lesion only, resection of the posterosuperior process of the calcaneus, or a combination of both; suturing of the reflected tendon, wedge-shaped osteotomies of the calcaneus with and without fixations. Post-op requires immobilization with a short leg cast and partial WB for 3 weeks in a post-op shoe if the Achilles tendon was violated in surgery, to immediate ambulation so long as the Achilles insertion site was not violated during surgery. Type I: Once painful, surgical excision of the lesion is the definitive treatment. Willis et al, shows a 1.54% re-rupture rate post-op vs. 17.7% re-rupture rate with non- surgical methods. ‘Surgical procedures 1, DuVries’ total excision of mass (including total excision of Achilles tendon if it is calcified). Suture remaining triceps surae fragment to the peroneus longus and transfer the distal peroneal tendon to the insertion site on the calcaneus. 2. Reconstruction of Achilles tendon from a fascial graft from the triceps surae muscle, plantaris tendon, fascia lata tube graft, composite tissue grafts from the groin, and peroneus brevis tendon. 3. (Alternative to DuVries’ excision) Fixation of osseous fragments by figure eight wire and a long leg NWB cast with knee flexed 30° and ankle in equinus for 4-6 weeks plus 5 weeks in a short-leg WB cast in neutral ankle position. 4. For an Achilles tendon reconstruction and peroneus brevis graft, cast neutral to SPequinus. If bow-stringing occurs, cast 5° to 10° equinus for 2 weeks NWB then 4-6 weeks in a short-leg WB cast Post-op complications: infection, non-healing, painful or hypertrophic incision site, recurrence of symptoms, and a decreased loss of function as seen with re-rupture of tendon RD.Collman Tendo Achilles Rupture: Kuwada Kuwada GT: Classification of tendo achilles rupture with consideration of surgical repair techniques. J Foot Ankle Surg 29(4):361, 1990. ‘Type I: Partial tear of tendon ‘Type II: Complete rupture, defect <3 em ‘Tx: 8 wks cast immobilization if tear Repair: typically end-to-end anastomosis. Constitutes less than 50% of tendon. ‘Type IMI: Complete rupture, defect 3-6 em Type IV: Complete rupture, defect > 6 em ‘Repair: end-to-end anastomosis with Repair: gastrocnemius recession, followed autogenous tendon graft flap, possible by end-to-end anastomosis with a free augmentation with synthetic graft. and/or synthetic tendon graft. 80