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Emergency Med - Exam 2 > 19 - Midfoot Fractures > Flashcards

19 - Midfoot Fractures Flashcards

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1
Q

Objectives

A
  • Evaluation and treatment of midfoot fractures.

- Etiologies and mechanism of injury of midfoot fractures.

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2
Q

Overview

A
  • Fractures including navicular, cuneiforms, and cuboid
  • Often difficult to diagnose due to bony overlap on x-rays and accessory bones
  • May need to get contra-lateral films, bone scan, CT or MRI
  • Treatment is generally conservative if not displaced
  • ORIF often indicated if fracture is displaced or have large intra articular fragment
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3
Q

Navicular fractures

A
  • Most common midfoot fractures
  • 62% of all midfoot fractures
  • 0.37% of all fractures
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4
Q

Types of navicular fractures

A
  • Dorsal avulsion
  • Tuberosity
  • Body
  • Stress
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5
Q

Navicular blood supply

A
  • Due to large amount of articular cartilage, blood supply
    comes dorsally, plantarly and from tuberosity
  • Blood supply decreases with age
  • Good blood supply to medial and lateral 1/3 of navicular bone
  • Relative avascular area is the central 1/3 of navicular bone
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6
Q

Dorsal avulsion of navicular

A
  • Most common navicular fracture (47% of all navicular fractures)
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7
Q

Mechanism of injury of dorsal avulsion of navicular

A
  • Plantarflexion with inversion (talonavicular ligament fails)
  • Plantarflexion with eversion (dorsal tibionavicular ligament (part of deltoid) fails)
  • Can be seen with ankle sprains/injury
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8
Q

Diagnosis of dorsal avulsion of navicular

A
  • Best seen on lateral x-ray

- Pain, edema, and point tenderness dorsally and dorsomedially at talonavicular junction

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9
Q

Treatment of dorsal avulsion of navicular

A
  • Generally conservative with 4-6 weeks WB cast in neutral position
  • Surgery indicated if:
    o Fragment still symptomatic after immobilization
    o Fragment involves > 20% of articular cartilage
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10
Q

Navicular tuberosity fracture

A
  • 24% of all navicular fracture
  • Often confused with accessory navicular
  • Accessory usually bilateral
  • Has smoother edges with round appearance
  • Accessory navicular can also be symptomatic if fibrous union disrupted
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11
Q

Mechanism of injury of navicular tuberosity

A
  • Eversion

- Pull of Posterior tibial tendon or spring ligament causes avulsion

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12
Q

Clinical evaluation of navicular tuberosity fracture

A
  • Pain over navicular tuberosity with WB

- Pain with eversion of foot

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13
Q

X-ray findings of navicular tuberosity fracture

A
  • Seen best on lateral oblique

- Fragment usually not displaced due to soft tissue attachments

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14
Q

Treatment of navicular tuberosity fracture

A
  • Usually conservative w/ WB cast 4-6 wks in neutral or slightly plantarflex and inverted position
  • Surgery indicated if:
    o Nonunion with continued symptoms after immobilization
    o Significant displacement – usually > 5mm
    o ORIF if fragment large and significant cartilage involvement
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15
Q

Navicular body fracture

A
  • Incidence: 29% of all navicular fractures
  • Types
    o Nondisplaced (vertical or horizontal)
    o Displaced
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16
Q

Mechanism of injury for nondisplaced navicular body fracture

A
  • Multiple – usually fall with foot striking plantarflexed
  • Foot then may abduct or rotate causing fracture
  • Navicular gets trapped between cuneiforms and talus
  • Forced dorsiflexion of the forefoot on a pronated rearfoot
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17
Q

Diagnosis for nondisplaced navicular body fracture

A
  • Usually best seen on oblique and lateral views
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18
Q

Treatment for nondisplaced navicular body fracture

A
  • Short leg walking cast 6-8 weeks
19
Q

Mechanism of injury for displaced navicular body fracture

A
  • Foot strikes plantarflexed and then buckles at midfoot

- This causes soft tissues fail and allow displacement

20
Q

Types of displaced navicular body fractures

A

I – Transverse fracture

o Dorsal fragment

21
Q

Treatment for displaced navicular body fracture

A
  • Closed reduction difficult due to soft tissue attachments
  • Usually require ORIF with NWB short leg cast 6-8 weeks
  • May need ex-fix if highly comminuted or arthrodesis
22
Q

Complication rate for displaced navicular body fracture

A
  • Sangeorzan et al showed 28.5% rate of aseptic necrosis

- Postoperative arthritis common

23
Q

Navicular stress fracture

A
  • Accounts for 15% of pedal stress fractures in athletes
  • Usually occurs @ central to lateral 1/3 of the body – this area relatively avascular
  • Usually occurs in track and field athletes (sprints, hurdles etc.)
24
Q

Navicular stress fracture clinical findings

A
  • Clinical suspicion must be high
  • Pain dorsum of foot and medial arch
  • Direct pain with palpation and little edema
  • Pain with single leg heal rise
  • Exacerbated with activity and relieved by rest
25
Q

Navicular stress fracture radiographs

A
  • X-rays often negative especially initially
  • Usually best seen on AP view
  • Get bone scan or CT
26
Q

Navicular stress fracture treatment

A
  • NWB cast for 6-8 weeks
  • Palpate area of stress fracture
  • If pain continue, immobilization is needed
  • If not may start physical therapy and increased activity
  • Full activity at 3-6 months with orthotics
  • If fracture becomes complete and/or goes to nonunion ORIF may be necessary with bone graft
27
Q

CASE STUDY

A
  • An 18 year old male high school baseball player experienced gradually increasing medial midfoot pain during the season. Oblique and lateral x-rays revealed no abnormalities, but an anteroposterior radiograph of his foot (a) revealed slight radiolucency at the navicular (arrow).
  • A coronal CT scan (b) demonstrated a nondisplaced stress fracture running through the navicular from dorsal to plantar (arrow)
  • The patient responded to 8 weeks in a non-weightbearing case and his immobilization was supplemented with noninvasive electromagnetic bone stimulation
28
Q

Notes on meta-analysis (Torg et al.)

A
  • Looked at different treatment modalities for the treatment of navicular stress fractures
  • 4 treatments
    o NWB cast for 6 weeks
    o NWB cast for less than 6 weeks
    o WB
    o Surgery
  • Looked at average time to return to activity
  • NWB led to less time to return to activity
29
Q

Cuneiform fracture incidence

A
  • 4.2% of tarsal fracture

- Often associated with other tarsal and/or metatarsal injuries

30
Q

Cuneiform fracture types

A
  • Avulsion: medial cuneiform from pull of AT tendon
  • Body: MOI is direct trauma or axial/rotational forces
  • Fracture/dislocation: MOI is foot striking in plantarflexion causing soft tissues to fail (often seen with Lis franc’s injury)
  • Stress fracture
31
Q

Treatment for cuneiform fracture

A

Displaced fracture or large fracture fragments
o Closed reduction with or without traction and percutaneous pinning
o ORIF
o NWB 6-8 weeks

Nondisplaced fracture
o WB cast or fracture walker for 6-8 weeks

32
Q

Cuboid fracture incidence

A
  • Rarely an isolated injury
33
Q

Types of cuboid fracture

A
  • avulsion
  • simple body fracture
  • compression
34
Q

Cuboid avulsion fracture

A

o Most common
o Pull of the inferior calcaneocuboid ligament
o Often associated with ankle sprains

35
Q

Cuboid simple body fracture

A

o Foot strikes in plantarflexed position with axial or rotary forces
o Direct trauma

36
Q

Compression cuboid fracture

A

o “Nutcracker fracture”
o When cuboid gets caught between the bases of met bases 4 & 5 and calcaneous
o MOI – severe abduction of foot, often in plantarflexed position
o Force of injury greater

37
Q

Clinical presentation of cuboid fracture

A
  • Pain along lateral column
  • Pain with passive abduction/adduction & inversion/eversion of midfoot
  • Other sources of cuboid pain: subluxed cuboid, peroneus longus tendonitis, os perineum, arthritis
38
Q

Radiographs of cuboid fracture

A
  • May be difficult to see on x-rays, so get all three views

- CT or MRI if suspicion high

39
Q

Treatment of cuboid fracture

A
  • Avulsion fracture or body fracture (nondisplaced): usually WB in boot or cast for 6 weeks
  • Comminuted/crush injuries: surgery usually warranted (ORIF, Ex-Fix, calcaneocuboid fusion)
  • Need to get cuboid back out to length in comminuted/crush injuries
40
Q

Conclusion

A
  • Midfoot fracture often hard to diagnose on x-ray due to bony overlap
  • Clinical suspicion needs to be high
  • Relatively rare fracture with navicular fracture being most common
  • Most can be treated conservatively unless fracture highly articular or displaced
41
Q

CASE STUDY 1

A

Patient
o 60-year-old female with foot trauma

Radiographs
o X-ray shows malalignment
o MRI shows darks spot

Stress fracture
o CAM boot with non-weightbearing status for 6 weeks
o Navicular is the key to being non-weightbearing
o Since the navicular has low vascularity, it needs to be non-weightbearing to promote healing

42
Q

CASE STUDY 2

A

Patient
o 17-year-old male reports to ED after vehicle backs over his midfoot
o Patient has noted pain and edema over midfoot
o Otherwise healthy

Radiographs
o X-ray shows fracture of cuboid and navicular with displacement

Initial treatment
o Patient sent home and allowed to be weightbearing
o Had continued pain
o Had new x-rays taken 5 days later

Returned after 5 days
o X-rays show displaced navicular and displaced fracture of cuboid
o CT shows the same, more detail

Treatment
o Surgery: ORIF, primary arthrodesis, external fixation (there is shortening from crush injury)
o The downfall of primary arthrodesis is that the patient will be stiff and he will continue going
o Regardless, he will likely have arthritis
o Ex-fix was determined to be the best option

Follow up
o External fixator removed
o Patient continued to have pain in foot with peroneal spasm and a locking of the STJ
o The next best treatment option was an arthrodesis
o 4 months later he was

43
Q

CASE 3

A

Patient
o 64-year-old female presents to clinic with midfoot pain that is not getting better
o Went to ER 3 months ago when her foot and angle “gave out” but they sent her home with no follow-up recommendation

X-rays
o Fracture of medial cuneiform
o Get a CT to follow up and confirm

PE 
o	Pain with palpation with medial midfoot and pain with midfoot range of motion 
o	Some swelling noted around the midfoot
o	No erythema or ecchymosis 
o	No pain with muscle strength testing

Where is the pathology?
o Medial cuneiform oblique fracture

Treatment
o Oblique fracture is an unstable fracture, so need ORIF since it has been there
o Could go more conservative, since there is good alignment so arthritis in the future is not a major concern
o Patient was placed in a CAM boot and allowed minimal weightbearing
o Bone stimulator was ordered
o Patient started to show decreased symptoms and signs of healing 6 weeks after initial presentation

Emergency Med - Exam 2 (11 decks)

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