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Orthopaedics > Foot Injury > Flashcards

Foot Injury Flashcards

1
Q

Learning Outcome:

A
  1. Talus fracture
  2. Calcaneus fracture
  3. Navicular fracture
  4. Lis Franc Injury
  5. Metatarsal fracture
  6. Base of 5th metatarsal fracture
  7. Sesamoid fracture
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2
Q

Talus fracture pathology

A
  1. Relatively uncommon
  2. Fracture sites

i. head (least common)
ii. neck (50%, most common)
iii. body (20%)
iv. lateral processes (10%)
v. posterior process
vi. osteochondral fracture

  1. Superior articular surface (major weightbearing)
  2. Mechanism of injury
    - neck: ankle hyperextension
    - body: axial loading
    - lateral process: eversion, external rotation
    - posterior process: avulsion from PTTL, PDL, PTFL or plantar flexion
  3. Hawkins classification for neck of talus fracture
    I - undisplaced (15% AVN)
    II -subtalar dislocation (20-50% AVN)
    III - subtalar, tibiotalar dislocation (20-100% AVN)
    IV - subtalar, tibiotalar, talonavicular dislocation (70-100% AVN)
  4. Lateral process fracture “snowboarding fracture”
    I - avulsion
    II - large fragment
    III -comminuted
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3
Q

Talas fracture diagnosis

A

HX:

  1. Trauma:
    - dorsiflexion/hyperextension: neck
    - axial loading: body
    - external rotation, eversion: lateral process
    - plantar flexion: posterior process
  2. Pain
  3. Swelling
  4. Bruises

PE: as other fractures

X-Ray

  1. AP: Lateral process
  2. Lateral: Posterior process
    * not to be mistaken from Os Trigonum (50% pt)
  3. Canale view: Talar neck
    * maximum equines position (aka foot 15 degree pronation, X-ray beam 75 degree from horizontal plane)

CT-Scan

  1. For lateral process fracture if not seen on X-Ray
  2. Determine degree of displacement, comminution
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5
Q

Calcaneum fracture pathology

A
  1. Most common tarsal bone fracture
  2. Mechanism of injury: axial loading (eg. fall from height)
  3. 20% associated with spine, pelvic or hip injury
4. Common fracture 
I. Extraarticular (25%)
- calcaneal tuberosity (achilles avulsion: emergency)
- anterior process (bifurcate ligament)
- sustentaculum tali
II. Intraarticular (75%)

Essex-Lopresti classification

  • Primary fracture line runs anterolateral to posteromedial, divides into 2 fragments: superomedial (constant), superolateral
  • Secondary fracture line runs:
  • beneath posterior facet: tongue-type
  • behind posterior facet: joint depression

Sanders classification
*based on CT-findings
I - Nondisplaced
II - Two part fracture of posterior facet
III - Three part fracture of posterior facet
IV - Comminuted

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6
Q

Calcaneum fracture diagnosis

A

HX:

  1. Trauma: axial loading, eg. fall from height
  2. Pain: Heel
  3. Swelling
  4. Bruises

PE:

  1. broad, squatted heel
  2. loss of concavity below lateral malleolus
  3. Tender heel when squeezed
  4. subtalar joint cannot be moved (inversion, eversion), ankle movement may still possible
  5. Haematoma: from medial ankle to sole of foot “Mondor’s sign”

X-Ray

  1. AP: Lateral wall extrusion causing fibular impingement
  2. Lateral: reduced Bohler’s angle (normal 20-40 degree), increase Gissane’s angle (normal 120-145 degree)
    * both indicates collapse of posterior facet
  3. Oblique:
  4. Broden view: posterior facet
  5. Harris view: calcaneal tuberosity fragment widening, shortening, varus positioning

CT-Scan (Gold Standard)

  1. 30 degree semicoronal: posterior, middle facet displacement
  2. axial: calcaneocuboid joint involvement
  3. sagittal: tuberosity displacement

MRI
- Stress fracture

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7
Q

Navicular fracture pathology

A
  1. Types of navicular fracture
    I - Cortical avulsion (avulsion by talonavicular ligament)
    II - Tuberosity fracture (avulsion by Posterior tibialis tendon)
    III - Body fracture
    IV - Stress fracture
  2. Sangeorzan Classification body of navicular fracture
    I - transverse in coronal plance, no forefoot angulation
    II - oblique, from dorsolateral to plantar medial, forefoot adduction
    III - Comminuted, forefoot abduction
  3. Mechanism of injury
    - navicular avulsion: excessive plantarflexion
    - tuberosity: excessive eversion
    - body: axial loading
    - stress: chronic overuse
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8
Q

Navicular fracture diagnosis

A

HX:

  1. Trauma:
    - axial loading: body
    - plantar flexion: avulsion navicular
    - eversion: tuberosity
    - stress: overuse
  2. Pain: Medial midfoot
  3. Swelling mild
  4. Bruises

PE:

  1. Midfoot swelling, tenderness
  2. Ankle joint, subtalar joint movement usually preserved

X-Ray

  1. Oblique (45degree): tuberosity
  2. Lateral: Transverse, avulsion
  3. AP: body

CT-Scan (Gold Standard)

  1. 30 degree semicoronal: posterior, middle facet displacement
  2. axial: calcaneocuboid joint involvement
  3. sagittal: tuberosity displacement

MRI
- Stress fracture

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9
Q

Lis Franc Injury pathology

A
  1. Disruption of TMT/Lis Franc joint complex, ranges from mild sprain to severe dislocation
  2. Classification
    I- Partial incongruity (not all are displaced)
    II - Total incongruity (all displaced in same direction)~Homolateral/Homomedial
    III - Divergent (medial + lateral displacement)
  3. Mechanism
    - direct: axial loading cause plntar displacement
    - indirect: axial loading on plantarflexed midfoot cause dorsal displacement or lateral displacement (++ cuboid ‘nutcracker’ fracture)
  4. Complication
    - 50% arthritis
    - altered gait
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10
Q

Lis Franc Injury diagnosis

A

HX:

  1. Trauma:
    - axial loading on plantarflexed foot
    - crush injury
  2. Pain: severe, unable to bear weight
  3. Swelling: midfoot
  4. Bruises: medial plantar

PE:

  1. Midfoot swelling, tenderness
  2. Medial plantar bruising
  3. Instability test
    - dorsal subluxation (if can, tear of plantar ligament: instability)
    - medial, lateral displacement: global instability
  4. Provocative test:
    - Forefoot abduction cause pain

X-Ray

  1. Lateral: Dorsal displacement of metatarsal
  2. AP:
    - malalignment between medial border of 2nd metatarsal and medial border of middle cuneiform
    - fleck sign: avulsion fracture (Lis Franc ligament)
    - widening of 1st and 2nd MTT ray >2mm
  3. Oblique: malalignment between medial border of 4th metatarsal and medial border of cuboid

MRI
- if suspect pure ligamentous injury

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11
Q

Metatarsal fracture pathology, diagnosis

A
  1. Four types:
    I - crush (direct injury)
    II - spiral fracture (twisting: fixed forefoot with rotated hindfoot or leg)
    III - avulsion (ligament pull)
    Iv - stress fracture (overuse)*commonest in 2nd
  2. Classification:
    - sites of fracture (head, neck, shaft, base)
    - pattern: transverse, spiral
    - displacement: medial, lateral, dorsal, plantar
    - angulation
    - intraarticular, extraarticular
  3. Diagnosis: as normal fracture
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12
Q

Base of 5th metatarsal fracture pathology

A

Types:

Zone 1 (93%):

  • avulsion fracture (peroneus bervis)
  • within 1.5 cm from tuberosity
  • blood supplied by metaphyseal artery
  • mechanism: excessive inversion

Zone 2 (4%):

  • Jones fracture
  • distal to 1.5 cm from tuberosity, within articular surface with 4th
  • avascular area
  • mechanism: adduction force from lateral

Zone 3 (3%):

  • Stress fracture
  • distal to articular surface with 4th
  • avascular area
  • mechanism: overuse eg: atheletes, pes cavus foot
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13
Q

Base of 5th metatarsal fracture diagnosis

A

Hx:

  1. Pain: lateral border of forefoot
  2. Swelling
  3. Bruising

Pe:

  1. Tenderness lateral border
  2. Foot inversion cause pain
  3. Resisted foot eversion: tendon

X-ray

  • transverse fracture, perpendicular to bone axis
  • if parallel, suggestive of apophysis, not fracture
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14
Q

Sesamoid fracture

A
  1. Epidemiology
    - tibial/medial sesamoid (more commonly injured, greater weight bearing status)
    - fibular/lateral sesamoid
  2. Mechanism: Toe hyperextension, axial loading
  3. DDX:
    - dislocation
    - FHB tendinitid
    - sesamoiditis
    - Turf toe (+mtp sprain)
  4. Diagnosis
    Hx: trauma, pain worse in terminal stance phase
    Pe: plantar flexed mtp (dislocated), tendenerness
    X-ray: Proximal migration, fracture
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Orthopaedics (47 decks)

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