Trauma - Foot and Ankle Flashcards
1
Q
What are the ligaments of the distal tibiofibular joint?
A
- Anterior inferior tibiofibular ligament
- Posterior inferior tibiofibular ligament
- Transverse tibiofibular ligament
- Interosseus ligament
2
Q
What are the lateral collateral ligaments of the ankle?
A
- Anterior talofibular ligament
- Posterior talofibular ligament
- Calcaneofibular ligament
3
Q
What are the medial collateral ligaments of the ankle?
[J Bone Joint Surg Am. 2014;96:e62(1-10)]
A
- Superficial layer of the deltoid ligament
- Tibionavicular ligament
- Tibiospring ligament
- Tibiocalcaneal ligament
- Superficial posterior tibiotalar ligament
2. Deep layer of the deltoid ligament - Deep anterior tibiotalar ligament
- Deep posterior tibiotalar ligament
4
Q
What are normal radiographic measurements at the ankle? (measurements 1cm proximal to plafond)
A
- AP view:
- Medial clear space = <4mm
- Equal to the superior clear space
- Tibiofibular clear space = <6mm
- Tibiofibular overlap = 6mm or greater
- Oblique/mortise view
- Tibiofibular clear space = <6mm
- Tibiofibular overlap = 1mm or greater
- Talocrural angle = 83°+/- 4°
- Or within 5°of the contralateral side
- Angle between a line drawn perpendicular to the distal tibia articular surface and a line connecting the tips of the medial and lateral malleoli
5
Q
What is the Lauge-Hansen Classification for ankle fractures?
A
Describes the position of the foot and the motion of the foot/talus with respect to the leg
- Supination adduction
- Weber equivalent = A
- Medial malleolus # = vertical
- Lateral malleolus # = transverse
- **Note: associated with marginal tibial plafond impaction
2. Supination external rotation - Weber equivalent = B
- Medial malleolus # = transverse
- Lateral malleolus # = short oblique starting at level of syndesmosis
- Pronation abduction
- Weber equivalent = C
- Medial malleolus # = transverse
- Lateral malleolus # = transverse comminuted fracture above the level of the syndesmosis
- Pronation external rotation
- Weber equivalent = C
- Medial malleolus # = transverse
- Lateral malleolus # = short oblique or spiral fracture above the level of the syndesmosis
6
Q
What are indications for surgery in ankle fractures?
[Miller’s, 6th ed.]
A
- Displaced bimalleolar and trimalleolar fractures
- Displaced lateral malleolar fractures with incompetent deltoid ligament (bimalleolar equivalent)
- Displaced medial malleolar fractures
- Syndesmosis disruption
- Posterior malleolar fractures >25%
7
Q
How can you assess fibular length intra-operatively?
A
- Compare to contralateral side
- Symmetry between the lateral talus and the medial fibula
- Restoration of Shenton line at the ankle
* Subchondral bone contour of the tibial plafond and fibula which should be smooth and unbroken - The “ball” or “dime sign”
* Described on the AP view as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length - Normal talocrural angle
* Shortened fibula will have an increased talocrural angle
8
Q
What are the eponymous ankle fracture fragments?
A
- Chaput
* AITFL avulses the anterolateral distal tibia - Volkmann
* PITFL avulses the posterolateral distal tibia - Wagstaffe
* AITFL avulses the anterior distal fibula
9
Q
What is a ‘Bosworth fracture-dislocation” of the ankle?
A
Fracture of the distal fibula with an associated fixed posterior dislocation of the proximal fibula fragment which becomes entrapped behind the posterior tibial tubercle
10
Q
What are the indications to fix posterior malleolus fractures?
[AAOS comprehensive review 2, 2014]
A
- Fracture >25% of the articular surface
- Persistent posterior talus subluxation following fixation of the fibula fracture
* Posterior malleolus fracture is often reduced via ligamentotaxis via the PITFL - Syndesmosis instability with associated posterior malleolus fracture
11
Q
What is the classification of posterior malleolus fractures based on patterns identified on CT?
[JAAOS 2013;21:32-40]
A
Haraguchi
- Type I
- Posterolateral oblique-type wedge fragment
- Most common
- Type II
- Fracture extends from the fibular notch to the medial malleolus
- May be one or two fragments
- “Double contour sign” evident proximal to the medial malleolus when there is posteromedial extension
- Fracture extends from the fibular notch to the medial malleolus
- Type III
- Shell-shaped avulsion at the posterior lip of the tibial plafond
12
Q
What are techniques for fixation of lateral malleolus fractures?
[Rockwood and Green 8th ed. 2015]
A
- Lag screw and neutralization plate
* Typically 3.5mm lag screw from AP or PA with a lateral 1/3 tubular plate with 3 bicortical screws proximal and 3 unicortical cancellous screws distal to the fracture - Posterior antiglide plating
- Locking plate
- Intramedullary nail
- Bridge plating for comminution
13
Q
What are the advantages and disadvantages of a posterior antiglide plate vs. a lateral neutralization plate when fixing a distal fibula fracture?
[Wheeless]
A
Advantages
- Biomechanically stronger
- Distal screws obtain bicortical purchase
- Distal screws avoid joint
- Plate is less prominent, less hardware irritation
- Posterior incision allows access to posterior malleolar fragment
Disadvantages
- Peroneal tendon irritation
14
Q
What are techniques for fixation of medial malleolus fractures?
[Rockwood and Green 8th ed. 2015]
A
- Two 4.0 partially threaded cancellous screws inserted unicortically parallel to each other and perpendicular to the fracture (consider washers)
- Tension band wiring
- Minifrag T-plate contoured for small fragments
- Medial buttress plate for vertical fractures
15
Q
What are techniques for fixation of posterior malleolar fractures?
[JAAOS 2013;21:32-40]
A
- Percutaneous
* AP lag screw after indirect reduction of posterior malleolar fracture through anatomic reduction of fibular fracture - Open
- Posterolateral approach using FHL and peroneal interval
- PA lag screw
- 4.0 partially threaded cancellous screw
- Posterior buttress plate
- Small frag T-plate
16
Q
What are the advantages of fixing the posterior malleolus vs. the fibula first?
A
- Posterior malleolus 1st = better evaluation of reduction on fluoro
* Fibular plate does not obscure - Fibula 1st = restores length aiding in reduction of the posterior malleolus
17
Q
What are techniques for fixation of syndesmosis disruption?
[Rockwood and Green 8th ed. 2015]
A
- Position screws
- Suture/wire construct (ie tightrope)
18
Q
What are techniques to augment fixation in osteoporotic bone when managing ankle fractures?
[JAAOS 2008;16:159-170] [Johal]
A
- Syndesmosis screws
- Locking plates
- Double stacking 1/3 semitubular plates
- Cement augmentation/Calcium phosphate cement
- Medial malleolar fixation with engagement of the far cortex with a cortical screw
- Longer plates
- TTC Steinman pin
- Supplementary K wires in plated fibulas
19
Q
What is the normal motion of the fibula during ankle ROM (rotation, translation, migration)?
[J Bone Joint Surg Am. 2014;96:603-13]
A
- With ankle plantar flexion, fibula:
- Migrates distally
- Translates anteromedially
- Internally rotates
- With ankle dorsiflexion, fibula:
- Migrates proximally
- Translates posterolaterally
- Externally rotates
20
Q
What ligaments contribute most to syndesmosis stability?
[J Bone Joint Surg Am. 2014;96:603-13]
A
- AITFL (35%)
- PITFL
- Deep PITFL (33%)
- Superficial PITFL (9%)
- ***Therefore, PITFL = 42% and contributes most to stability
- Interosseous ligament (22%)
21
Q
What are the typical fracture patterns associated with syndesmosis injuries?
[J Bone Joint Surg Am. 2014;96:603-13]
A
- Pronation external rotation (Weber C)
- Supination external rotation (Weber B)
- Maissonneuve fracture
22
Q
What is the most reliable radiographic finding in the detection of syndesmotic injuries?
[J Bone Joint Surg Am. 2014;96:603-13]
A
Tibiofibular clear space
- It is not affected by leg position
23
Q
What is the most common mechanism of syndesmotic injury?
[J Bone Joint Surg Am. 2014;96:603-13]
A
External rotation and hyperdorsiflexion
24
Q
What are techniques for intraoperative assessment of syndesmosis stability?
A
- Cotton test
- Direct translation of the fibula via a clamp or hook
- Lateral directed force
- Positive if lateral translation >2mm
- External rotation stress test
* Positive if medial clear space widens - Ankle arthroscopy
* Direct visualization of the AITFL and PITFL - Compare to opposite side
25
What are keys to avoid syndesmois malreduction?
[J Am Acad Orthop Surg 2015;23:510-518]
1. Anatomic reduction of fibula fracture (length, alignment, rotation)
2. Clamp should be placed at the level of the syndesmosis
* From the lateral malleolar ridge to the centre of the AP width of the tibia
3. Avoid overcompression with the clamp
4. Directly visualize reduction
5. Compare to opposite side via fluoro
26
What are the options for surgical stabilization of the syndesmosis?
1. Syndesmotic screws
2. Suture button
3. Posterior malleolar fracture fixation
27
What is the rate of syndesmosis malreduction after syndesmosis screw based on postop CT?
52% are malreduced
28
In the presence of a posterior malleolar fracture with syndesmosis instability, why should you fix the posterior malleolar fracture rather than syndesmosis screws?
[JAAOS 2013;21:32-40]
Fixation of posterior malleolar fractures results in:
* More anatomic reduction of the syndesmosis (vs. syndesmosis screws)
* Rstores the length of the PITFL
* Adds greater stability/stiffness (vs. syndesmosis screw)
* Restores 70% vs. 40% stiffness
* Prevents posterior translation of the fibula
29
What are the 3 typical tibia fragments following a pilon fracture due to intact ligaments?
1. Medial (deltoid ligament)
2. Posterolateral = Volkman (PITFL)
3. Anterolateral = Chaput (AITFL)
30
Based on a CT scan study what are the 6 major articular fragments in a pilon fracture (Topliss et al)?
[JAAOS 2011;19:612-622]
1. Anterior
2. Posterior
3. Anterolateral
4. Posterolateral
5. Medial
6. Die-punch
31
What are patient factors associated with increased risk of soft-tissue complications in pilon fractures?
[JAAOS 2011;19:612-622]
1. Malnutrition
2. Alcoholism
3. Diabetes
4. Neuropathy
5. PVD
6. Tobacco use
32
What are the pilon fracture patterns that are more common in older patients vs. younger patients?
[JAAOS 2011;19:612-622]
Older patients
* Coronal fractures
* Low energy injuries
* Valgus angulation
Younger patients
* Sagittal fractures
* High energy injuries
* Varus angulation
33
What does the assessment of soft tissue envelope include in a pilon fracture?
[JAAOS 2011;19:612-622]
1. Open/closed
2. Fracture blisters
3. Edema
4. Ecchymosis
34
What imaging is required for assessment of pilon fractures?
[JAAOS 2011;19:612-622]
1. Radiographs
* AP, lateral, mortise ankle views
* Full length AP and lateral tibia/fibula views
2. CT
* After initial ex-fix improves fracture fragment visualization secondary to ligamentotaxis
* Reasons to get CT include:
* Evaluate extent of articular involvement
* Determine surgical approach
* Determine need for bone graft
* Selection of implants
35
What are the goals of surgical management of pilon fractures?
[JAAOS 2011;19:612-622]
1. Ruedi and Allgower 4 principles (1969)
* Restore the length of the fibula
* Anatomic reconstruction of the tibial articular surface
* Bone graft gaps left by impaction and comminution
* Stable internal fixation with a medial tibial plate (buttress)
2. JAAOS 2011
* Reconstruction of the articular surface
* Restoration of the mechanical axis
* Stable fixation to allow early ROM
* Correct valgus deformity of the distal tibia
3. Petrisor grand rounds – general fixation strategy
* Begin with posterolateral fragment
* Constant fragment
* Fix posteromedial to posterolateral fragment
* Reduce central impaction
* Reduce anterolateral fragment
* Provisional wire fixation
* Lag screw fixation
* Fix articular block to diaphysis
36
With respect to timing, when is definitive ORIF of pilon fractures indicated?
[JAAOS 2011;19:612-622]
Resolution of soft tissue injury determined clinically by:
* Resolution of ecchymosis over surgical site
* Re-epithelization of fracture blisters
* Healing of open fracture wounds without infection
* Resolution of soft tissue edema sufficient to allow skin wrinkle (‘wrinkle test’)
\*\*\*Takes 10 days – 3 weeks
37
Why should fibula fixation be delayed rather than fixed at time of ex-fix of a pilon fracture?
[JAAOS 2011;19:612-622]
1. Nonanatomic reduction of fibula impedes tibia reduction
2. Higher fibular wound complication
3. Limits incision choices at time of definitive surgery
38
What determines the surgical approach used for ORIF of a pilon fracture?
[JAAOS 2011;19:612-622]
Soft-tissue injury and fracture pattern
39
What locked plate options are available for the distal tibia?
[JAAOS 2011;19:612-622]
1. Medial
2. Anterolateral
3. Posterior
40
What is the most common fracture involving the talus?
[Rockwood and Green 8th ed. 2015]
Lateral talar process fracture (snowboarder’s fracture)
41
What are the types of talus fractures?
[Rockwood and Green 8th ed. 2015]
1. Process fractures
* Lateral process (most common)
* Medial tubercle of posterior process
* Lateral tubercle of posterior process
2. Talar neck
* Most common type
* Account for 50% of all talus fractures [Foot and Ankle Surgery 2017]
3. Talar body
4. Talar head
42
What structure inserts on the lateral talar process?
[Rockwood and Green 8th ed. 2015]
Lateral talocalcaneal ligament
\*\*\*Note – the lateral talar process articulates with the fibula (dorsolaterally) and the anterior portion of the posterior facet of the calcaneus (inferomedially)
43
The posterior process of the talus has a medial and a lateral tubercle – what inserts on each tubercle?
[Rockwood and Green 8th ed. 2015]
1. Medial tubercle – deltoid ligament
2. Lateral tubercle – posterior talofibular ligament (PTFL)
44
What are the typical mechanisms of injury for each talus fracture type?
[Rockwood and Green 8th ed. 2015]
1. Processes - often avulsion type or loading
2. Talar neck - Hyperdorsiflexion
* Neck of talus impacts anterior distal tibia
3. Talar body - Axial compression
* Load between tibial plafond and calcaneous
4. Talar head - Axial load along longitudinal axis of foot
* Navicular loads the head
45
In fracture dislocations of the talus, when the talar body dislocates from the mortise where does it come to lie?
[Rockwood and Green 8th ed. 2015]
Posteromedial
* Between the medial malleolus and the Achilles tendon
* Rotates on an intact deltoid ligament
46
What percentage of talus fractures are open?
[Foot and Ankle Surgery 2017]
20%
47
What is the blood supply of the talus?
[Rockwood and Green 8th ed. 2015]
1. Branches of the 3 main arteries of the leg
* Posterior tibial artery
* Branch = Artery of the tarsal canal
* Branch = deltoid artery supplies the medial 1/3 of the body
* Anterior tibial/dorsalis pedis artery
* Branches = multiple perforate the dorsal aspect of the neck supplies the talar head
* (Perforating) Peroneal artery
* Branch = artery of the tarsal sinus
* Branch = artery to the posterior process
2. ‘Anastamotic sling’ is formed inferior to the neck by the artery of the tarsal sinus and tarsal canal
* Provide perforators that flow retrograde to supply the body
48
What is the average talar neck angle?
[Foot and Ankle Surgery 2017]
Approx.. 24° medially (range 10-44)
49
What special radiographic view can be used to visualize the talar neck?
[Rockwood and Green 8th ed. 2015]
Canale and Kelly view
* Ankle max plantarflexion, foot 15° pronation, beam 75° from horizontal
* Demonstrates the medial talar neck allowing assessment of medial comminution and varus malalignment
50
What anatomic landmark can be used to distinguish talar neck fractures from talar body fractures?
[Rockwood and Green 8th ed. 2015]
Lateral talar process
* Fractures anterior are talar neck and fractures posterior are talar body
51
What is the Hawkins classification of talus fractures?
[Rockwood and Green 8th ed. 2015]
TYPE I
* **Undisplaced** talar neck fracture
* No joint dislocations
TYPE II
* Talar neck fracture with subluxation or dislocation of the **subtalar** joint (most common)
* IIA - subluxed subtalar joint (No AVN - 0%)
* IIB - dislocated subtalar joint (Higher AVN risk - 25%)
* \*\*\*IIA/B added by Vallier et al in 2000 [J Bone Joint Surg Am. 2014;96:192-7]
TYPE III
* Talar neck fracture with dislocation of the **ankle mortise** and subtalar joint
TYPE IV
* Talar neck fracture with subluxation or dislocation of the **talonavicular joint** and ankle mortise and subtalar joint
52
What is the incidence of each type and rate of osteonecrosis following talar neck fractures based on Hawkins classification?
[Current Reviews in Musculoskeletal Medicine (2018) 11:456–474]
Current Reviews in Musculoskeletal Medicine (2018) 11:456–474
* See Table
J Orthop Trauma 2015;29:210–215
* All dates:
* Type I - 10%
* Type II - 27%
* Type III - 53%
* Type IV - 48%
* Since 2000:
* Type I - 8%
* Type II - 21%
* Type III - 45%
* Type IV - 37%
53
In the context of a talar neck fracture, what is the greatest risk factor for developing post-traumatic arthritis?
[J Bone Joint Surg Am. 2014;96:192-7]
Associated talar body fracture
* 83% of patients with talar neck + body fractures developed posttraumatic OA
Other risk factors:
* Hawkins III fractures (subtalar + tibiotalar displacement)
* 56% subtalar arthritis
* 59% tibiotalar arthritis
* Concurrent calcaneus and/or plafond fractures
* 75% develop OA
\*\*\*Post-traumatic OA is most common complication after talar neck fracture
54
What are the closed reduction maneuvers for Type II and Type III talus fractures?
[Rockwood and Green 8th ed. 2015]
Type II
* Flex the knee
* Plantarflex the ankle
* Correct varus/valgus malalignment
* Maintain the ankle in slight equinus
Type III
* Flex the knee
* Plantarflex the ankle
* Foot in varus
* Direct pressure to the talar body
55
Where are the typical locations of comminution in talar neck fractures?
Dorsal and medial
* Failure to recognize leads to malalignment in varus and extension
56
What talar neck fractures are suitable for nonoperative treatment?
[Rockwood and Green 8th ed. 2015]
Hawkins I – nondisplaced (must be confirmed on CT)
57
What is the postoperative management of a talar neck ORIF?
NonWB for 8 weeks in boot
* Progressive WB until 12 weeks
* After 12 weeks full WB
58
What are the surgical principles for talar neck fracture ORIF?
[Rockwood and Green 8th ed. 2015]
1. Combined anterolateral and anteromedial
* Better judgement of anatomic reduction with dual approach
* Anteromedial approach
* Incision from anterior medial malleolus to the navicular
* Between tibialis anterior and tibialis posterior tendons
* Anterolateral approach
* Anterior to the fibula, lateral to EDL
* In line with the 4th MT
* Elevate EDB
2. Avoid excessive soft tissue stripping
* ‘Iatrogenic osteonecrosis’
3. Reduction may be assisted with universal distractor (tibia to calcaneus), Shanz pins or medial malleolus osteotomy (for dislocated talus) and held provisionally with K-wires
4. Fixation options:
* AP screw
* Generally not perpendicular to fracture line
* Use noncompressive, fully threaded ‘buttress screw’
* PA screw
* More perpendicular to fracture line
* Posterolateral approach required on either side of the FHL groove and directed anteromedial
* Must be countersunk
* Cannulated screws can be used
* Lateral plate
* 2 or 2.4mm plate placed on the inferior margin of the lateral talus from head to lateral process
* Medial plate
* Less area for plate
59
Which screw orientation has been shown to be biomechanically superior for fixation of talar neck fractures?
[Foot and Ankle Surgery 2017]
PA screw
60
What structures should not be dissected to preserve the blood supply to the talus?
[Foot and Ankle Surgery 2017]
1. Deltoid ligament
2. Inferior talus neck
3. Sinus tarsi
61
How do you avoid varus and extension malreduction of talar neck fractures?
[JOT 2015;29:385–392]
1. Direct visualization of the cortical reduction reads of the lateral talar neck via the anterolateral approach
2. Dorsal and medial cortical deficiency can be bone grafted with local bone graft or allograft
62
How and when is the medial malleolus osteotomy performed?
[Wiesel 2nd ed. 2015]
1. Predrill and tap for 2 parallel screws
* 3.5 fully threaded cortical or 4.0 partially threaded cancellous
2. Oblique osteotomy directed to the shoulder and perpendicular to the line of the screws
* Oscillating saw to the medial subchondral bone then completed with an osteotome
3. Medial malleolus is rotated inferiorly leaving the deltoid (and blood supply to talus) intact
4. Typically indicated for talar body fractures where the fracture line extends posterior to the midpoint
63
What is the timing for surgical management of talus fractures?
[Curr Rev Musculoskelet Med. 2018 Sep;11(3):456-474]
1. Emergent management
* Open
* Extruded talus
* Irreducible dislocations
2. Delayed fixation
* Indicated if closed reduction can be achieved
* Allow for soft tissues to be amenable
64
What is the management of an extruded talus?
[Rockwood and Green 8th ed. 2015]
1. Talectemy
* Indicated when talus lost at scene or significantly comminuted and contaminated
* Principles:
* Maintenance of length and alignment with the use of spanning external fixation
* Followed by tibiocalcaneal fusion
2. Irrigation and debridement with talus reimplantation and internal/external fixation
* Indicated when a clean surgical bed can be achieved
65
What is the Hawkins Sign, when is it visualized, what is it’s significance?
[Rockwood and Green 8th ed. 2015]
Lucency in the subchondral area of the talar dome
* Visualized on an ankle AP view
* Occurs between 6-8 weeks post-fracture
* Indicates viability of the talus
* Begins in the medial subchondral bone of the talar dome and progresses laterally [American Journal of Roentgenology. 2003;181: 1559-1563]
* Partial AVN affects the lateral talar dome
66
What are the complications following talus fractures?
1. Wound breakdown
2. Infection
3. AVN
* Typically managed with observation
* Limit WB
* Allow for creeping substitution
4. Nonunion/delayed union
5. Malunion (varus neck)
* Due to medial comminution
* Treat with medial opening wedge
6. Post-traumatic OA [Curr Rev Musculoskelet Med. 2018 Sep;11(3):456-474]
* Most common complications
* Overall rate of 51.69–67.8%
* Subtalar \> tibiotalar \> TN
* Treat with fusion
* More common with talar body fractures than talar neck [JOT 2015;29:385–392]
67
What is the proposed algorithm for talar head fractures by Ibrahim?
[Foot and Ankle Surgery 2017]
1. Undisplaced
* Nonoperative
2. Displaced
* \>50% talar head involvement or talonavicular joint instability
* ORIF with immobilization and non-weight bearing for 6–8 weeks postoperatively
* \<50% talar head involvement and no instability of the talonavicular joint
* Excision of fracture fragments
* Closure of the talonavicular joint capsule
* Period of immobilization and non-weight bearing
3. Severe talar head or navicular comminution
* Consider TN fusion
68
What is the definition of a subtalar dislocation?
[Rockwood and Green 8th ed. 2015]
Simultaneous dislocation of the talocalcaneal and talonavicular joints
69
What direction is the most common type of subtalar dislocation?
1. Medial dislocation (up to 85%)
* Calcaneus and foot displace medially
* Talar head is prominent dorsolateral
* Mechanism – inversion
2. Lateral dislocation
* Calcaneus and foot displace laterally
* Talar head is prominent medial
* Mechanism - eversion
* Associated with higher energy mechanisms
* Worse long term prognosis
70
What are the associated fractures with a medial vs. lateral subtalar dislocation?
[Miller’s, 6th ed.]
1. Medial
* Dorsomedial talar head
* Lateral navicular
* Posterior tubercle of talus
2. Lateral
* Cuboid
* Anterior process of calcaneus
* Lateral process of talus
* Lateral malleolus
71
What is the management of a subtalar dislocation?
[Rockwood and Green 8th ed. 2015]
1. Prompt closed reduction
* Adequate relaxation and sedation
* Flex the knee
* Exaggerate the deformity
* Longitudinal traction with countertraction
* Digital pressure applied to talar head
2. Confirm reduction with clinical exam, radiographs and CT scan
* Assess for intra-articular fragments and joint congruity
3. Immobilization for ~2 weeks until pain and swelling subside followed by physical therapy
72
What are the blocks to reduction of a subtalar dislocation?
[Rockwood and Green 8th ed. 2015]
1. Medial dislocation
* Talonavicular joint capsule
* Extensor retinaculum
* Extensor tendons
* Extensor digitorum brevis
* Deep peroneal nerve
* Dorsalis pedis artery
2. Lateral dislocation
* Tibialis posterior tendon
* FHL
* FDL
73
What injuries are commonly associated with calcaneus fractures?
[Rockwood and Green 8th ed. 2015]
1. Lumbar spine fractures
2. Talar neck
3. Tibial pilon
4. Tibial plateau
74
What is the mechanism of an anterior process fracture of the calcaneus?
[Rockwood and Green 8th ed. 2015]
Inversion and plantarflexion
* ‘Sprain fracture’
* Results in an avulsion fracture at the bifurcate ligament attachment
\*\*\*NOTE – bifurcate ligament arises from the anterior process and splits to insert on to the dorsal cuboid and dorsolateral navicular
75
What two angles should be assessed for loss of calcaneal height; ‘flattening’?
1. Bohler angle
* Angle formed between line from superior aspect of calcaneal tuberosity and posterior facet and line from superior aspect of anterior process and posterior facet
* Normal = 20-40
* Fracture = decreased angle
2. Critical angle of Gissane
* Angle formed between the line along the downslope of the posterior facet and the line along the upslope of the anterior process
* Normal = 120-145
* Fracture = increased angle
76
What are the dedicated radiographic views for the calcaneus?
1. Broden’s view
* Demonstrates the articular surface of the posterior facet
* Foot is in neutral dorsiflexion, leg is internally rotated 30-40°
* Four radiographs are made at 40°, 30°, 20° and 10° of cephalad tilt
* 10° shows the posterior aspect of the facet
* 40° shows the anterior aspect of the facet
2. Harris axial view
* Demonstrates the body of the calcaneus and subtalar joint
* Patient is standing on the cassette and the beam is directed 45° caudal from behind
77
What direction is the most common type of subtalar dislocation?
1. Medial dislocation (up to 85%)
* Calcaneus and foot displace medially
* Talar head is prominent dorsolateral
* Mechanism – inversion
2. Lateral dislocation
* Calcaneus and foot displace laterally
* Talar head is prominent medial
* Mechanism - eversion
* Associated with higher energy mechanisms
* Worse long term prognosis
78
What are the associated fractures with a medial vs. lateral subtalar dislocation?
[Miller’s, 6th ed.]
1. Medial
* Dorsomedial talar head
* Lateral navicular
* Posterior tubercle of talus
2. Lateral
* Cuboid
* Anterior process of calcaneus
* Lateral process of talus
* Lateral malleolus
79
What is the management of a subtalar dislocation?
[Rockwood and Green 8th ed. 2015]
1. Prompt closed reduction
* Adequate relaxation and sedation
* Flex the knee
* Exaggerate the deformity
* Longitudinal traction with countertraction
* Digital pressure applied to talar head
2. Confirm reduction with clinical exam, radiographs and CT scan
* Assess for intra-articular fragments and joint congruity
3. Immobilization for ~2 weeks until pain and swelling subside followed by physical therapy
80
What is the classical resulting deformity of the calcaneus after a displaced intra-articular fracture?
[Rockwood and Green 8th ed. 2015]
1. Loss of height
2. Shortened and widened heel
3. Varus malalignment
81
What are the blocks to reduction of a subtalar dislocation?
[Rockwood and Green 8th ed. 2015]
1. Medial dislocation
* Talonavicular joint capsule
* Extensor retinaculum
* Extensor tendons
* Extensor digitorum brevis
* Deep peroneal nerve
* Dorsalis pedis artery
2. Lateral dislocation
* Tibialis posterior tendon
* FHL
* FDL
82
What injuries are commonly associated with calcaneus fractures?
[Rockwood and Green 8th ed. 2015]
1. Lumbar spine fractures
2. Talar neck
3. Tibial pilon
4. Tibial plateau
83
What is the mechanism of an anterior process fracture of the calcaneus?
[Rockwood and Green 8th ed. 2015]
Inversion and plantarflexion
* ‘Sprain fracture’
* Results in an avulsion fracture at the bifurcate ligament attachment
\*\*\*NOTE – bifurcate ligament arises from the anterior process and splits to insert on to the dorsal cuboid and dorsolateral navicular
84
What two angles should be assessed for loss of calcaneal height; ‘flattening’?
1. Bohler angle
* Angle formed between line from superior aspect of calcaneal tuberosity and posterior facet and line from superior aspect of anterior process and posterior facet
* Normal = 20-40
* Fracture = decreased angle
2. Critical angle of Gissane
* Angle formed between the line along the downslope of the posterior facet and the line along the upslope of the anterior process
* Normal = 120-145
* Fracture = increased angle
85
What are the dedicated radiographic views for the calcaneus?
1. Broden’s view
* Demonstrates the articular surface of the posterior facet
* Foot is in neutral dorsiflexion, leg is internally rotated 30-40°
* Four radiographs are made at 40°, 30°, 20° and 10° of cephalad tilt
* 10° shows the posterior aspect of the facet
* 40° shows the anterior aspect of the facet
2. Harris axial view
* Demonstrates the body of the calcaneus and subtalar joint
* Patient is standing on the cassette and the beam is directed 45° caudal from behind
86
What is the classical resulting deformity of the calcaneus after a displaced intra-articular fracture?
[Rockwood and Green 8th ed. 2015]
1. Loss of height
2. Shortened and widened heel
3. Varus malalignment
87
What are the fragments resulting from a displaced intra-articular calcaneal fracture?
[Rockwood and Green 8th ed. 2015]
1. Anterolateral
* Lateral wall of the anterior process
* May include portion of the CC articulation
2. Anterior main
* Anterior to primary fracture line
* Usually includes anterior process and anterior portion of sustentaculum
3. Superomedial
* ‘Constant fragment’
* Posterior to primary fracture line
* Includes the remaining sustentaculum
4. Superolateral
* Lateral portion of the posterior facet
5. Posterior main
* Represents the posterior tuberosity
6. Tongue
* Superolateral fragment that remains attached to a portion of the posterior tuberosity including the Achilles insertion
88
What is the Essex-Lopresti classification of calcaneus fractures?
[Rockwood and Green 8th ed. 2015][Orthobullets]
1. Primary fracture line is oblique from lateral to medial through the posterior facet dividing it into two fragments
2. The secondary fracture line determines the type:
* Tongue-type
* Secondary fracture line exits at the posterior aspect of the tuberosity
* Articular fragment remains attached to the tuberosity fragment
* Joint-depression-type
* Secondary fracture line exits posterior to the posterior facet
* Articular fragment is separate from the tuberosity fragment
89
What is the Sander’s classification of calcaneus fractures?
[Rockwood and Green 8th ed. 2015]
Coronal CT scan slice at widest undersurface of the posterior facet of the talus
* The posterior facet is divided into 3 equal columns and the lines are extended across to the posterior facet of the calcaneus dividing it into 3 equal fragments
* Medial, central, lateral plus the sustentaculum)
Type I
* Nondisplaced fracture (\<2mm) regardless of number of fracture lines
Type II
* One fracture line
* 2 fragments
* Subtypes IA, IB, IC
Type III
* Two fracture lines
* 3 fragments
* Subtypes IIAB, IIAC, IIBC
Type IV
* Three or more fracture lines
* Four or more fragments
90
According to Buckley et al (2002), which factors lead to better results after ORIF for displaced intra-articular calcaneal fractures?
1. Women
2. No Workers’ Compensation
3. Younger patients (age \<29)
4. Böhler angle \>15°
* Patients with Böhler angle \<15° do poorly regardless of treatment
5. Lighter workload
6. Single, simple displaced intra-articular calcaneal fracture
91
According to Buckley et al (2002), which factors lead to better results with nonoperative management for displaced intra-articular calcaneal fractures?
1. Age \>50
2. Males
3. Workers’ Compensation
4. Heavy workload
5. Böhler angle \>15°
* Patients with Böhler angle \<15° do poorly regardless of treatment
92
What are indications for nonoperative management of calcaneal fractures?
[Rockwood and Green 8th ed. 2015]
1. Non-displaced or minimally displaced extra-articular fractures
2. Nondisplaced intra-articular fracture
3. Anterior process fracture with \<25% involvement of CC joint
4. Poor surgical candidate
* PVD
* Insulin-dependent DM
* Minimal ambulation
* Comorbidites prohibiting surgery
93
What are the operative indications for calcaneal fractures?
[Rockwood and Green 8th ed. 2015]
1. Displaced intra-articular fracture of the posterior facet
2. Anterior process fracture with \>25% involvement of CC joint
3. Displaced calcaneal tuberosity fractures
4. Fracture-dislocation of the calcaneus
5. Selected open fractures
94
What are indications for percutaneous or minimally invasive surgery for calcaneus fractures?
[Rockwood and Green 8th ed. 2015]
1. Tongue-type fracture with posterior facet attached to tongue fragment
2. Displaced calcaneal tuberosity fractures
3. Temporary fixation in severe or impending soft tissue compromise from displaced fragments
4. Patients with relative contraindications (poor surgical candidates)
95
What is the wrinkle test in context of calcaneus fractures?
[Rockwood and Green 8th ed. 2015]
Ankle is placed in dorsiflexion and eversion
* Positive test = skin wrinkling is seen and no pitting edema is present
* Indicates operative intervention may be safely undertaken
96
What is the longest surgical delay generally accepted for calcaneus fractures?
3 weeks (beyond fracture consolidation starts)
97
What are the surgical principles to ORIF of intra-articular calcaneus fractures?
[Rockwood and Green 8th ed. 2015]
1. Extensile lateral approach
* “No touch full thickness incision”
* K-wire retractors in cuboid, talar neck and fibula
2. Place a Schantz pin in the calcaneal tuberosity
* Distract plantar and varus to disimpact fragments
3. Elevate the lateral wall fragment (retract or resect)
4. Reconstruct the articular surface
* Provisional K-wire fixation
* Build medial to lateral off the superomedial ‘constant’ fragment
5. Fix the anterior process and anterolateral fragment to the articular fragment
* Provisional K-wire fixation
6. Fix the tuberosity to the body
* Provisional K-wire fixation
7. Fill bone voids with bone graft or substitute
8. Replace the lateral wall
9. Definitive fixation with anatomic calcaneal plate
* Cortical lag screws for the articular fragment directed to the sustentaculum
* Avoid inferior placement into FHL
* Two screws in posterior tuberosity
* Two screws in anterior process
10. Assess peroneal tendons
* Repair superior peroneal retinaculum if unstable
11. Wound closure
* 0 vicryl for deep layer
* Place all sutures in figure-8 fashion then hand tie sequentially to apex
* 3-0 nylon in modified Allgöwer-Donati technique
98
What is the postoperative management after calcaneal ORIF?
[Rockwood and Green 8th ed. 2015]
1. Cast off 3 weeks then aircast
2. Sutures out when clean and dry
3. ROM starts early
4. nonWB for 12 weeks
* Then progress to fullWB and shoes as tolerated
99
What are risk factors for wound complications following the extensile lateral calcaneal approach?
1. Smoking
2. Substance abuse
3. Diabetes
4. Open fractures
5. High BMI
6. Single layer closure
100
What are the indications for less invasive surgical approaches for calcaneus fractures?
1. Displaced Essex-Lopresti fractures
2. Sanders type II fractures
3. Sanders type III fractures in patients with multiple comorbidities
4. Fracture variants with minimal posterior facet fragment comminution
5. Consider in diabetics, smokers, obese, PVD, soft tissue compromise
101
What are the less invasive surgical approach options for calcaneus fractures?
[JAAOS 2015;23:399-407]
1. Limited sinus tarsi approach
2. Percutaneous fixation
3. Arthroscopic-assisted reduction and fixation
102
What is the limited incision sinus tarsi approach for calcaneus fractures?
[JAAOS 2015;23:399-407]
1. 2-4cm incision from tip of fibula to the base of the 4th metatarsal
2. EDB is retracted cephalad
3. Fibrous tissue and fat is removed from sinus to allow visualization of posterior facet
103
What are the portals for the arthroscopic-assisted reduction and fixation of calcaneus fractures?
[JAAOS 2015;23:399-407]
Anterolateral and posterolateral
104
What are the technical considerations for fixation of calcaneal fractures with less invasive approaches?
[JAAOS 2015;23:399-407]
1. Schanz pin for reduction
* Placed through a stab incision in the posteroinferior calcaneal tuberosity from lateral to medial
* Allows for distraction, provide control of the tuberosity fragment, and aid reduction
2. Three point external fixator for reduction
* Pins in distal tibia, calcaneus and cuboid
* Freer through stab incision to reduce posterior facet
* Alternative to Schanz pin for reduction
3. Lateral to medial screws to engage sustentaculum
* Stabilizes posterior facet and restores calcaneal height
4. Posterior to anterior fully threaded cannulated screws
* Maintains axial length
5. Buttress screw
* From tuberosity to subchondral bone of the posterior facet
* Acts as a kickstand to maintain height
6. Low profile plate placed laterally
* Screws in tuberosity and anterolateral fragment
* Alternative to kickstand screw to maintain height
105
What percentage of Lisfranc injuries are missed?
[JAAOS 2017;25:469-479]
Up to 20% are missed initially
106
What are the consequences of untreated Lisfranc injuries?
[JAAOS 2017;25:469-479]
1. Painful posttraumatic arthritis
2. Arch collapse
107
What joints are included in the tarsometatarsal (Lisfranc) joint complex?
[JAAOS 2017;25:469-479]
1. Tarsometatarsal (TMT) joints
2. Intertarsal joints
3. Proximal intermetatarsal joints
108
What are considered the ‘keystones’ to the transverse (Roman) arch of the foot?
[JAAOS 2017;25:469-479]
1. Middle cuneiform
2. Base of the second metatarsal
109
What is unique about the base of the second metatarsal?
[JAAOS 2017;25:469-479]
1. The middle cuneiform is proximal to the medial and lateral cuneiforms allowing the base of the second metatarsal to be recessed (creates a mortise configuration) adding stability
2. The second metatarsal base has 5 articulations
110
What anatomic variations predispose to Lisfranc injuries?
[JAAOS 2017;25:469-479]
1. Short second metatarsal
2. Decreased depth of second TMT mortise
111
What are the static and dynamic stabilizers of the Lisfranc joint complex?
[JAAOS 2017;25:469-479]
1. Static
* Transverse intermetatarsal ligaments
* Between bases of 2-5 MT
* Lisfranc ligament
* Interosseous ligament between medial cuneiform and base of the 2nd MT
* Plantar oblique ligament
* Medial cuneiform to the 2nd MT [deep band] and 3rd MT [superficial band]
* \*\*\*NOTE: plantar ligaments are stronger than dorsal
2. Dynamic
* Tibialis anterior
* NOTE: can become entrapped between the medial and middle cuneiforms, precluding reduction
* Peroneus longus
112
What artery can be avulsed in more severe Lisfranc injury patterns leading to dorsal hematoma or compartment syndrome?
[JAAOS 2017;25:469-479]
Dorsalis pedis artery
113
What bones contribute to the medial, middle and lateral columns of the TMT joint complex?
[JAAOS 2017;25:469-479]
1. Medial
* Medial cuneiform and 1st MT
2. Middle
* Middle cuneiform, lateral cuneiform and 2nd and 3rd MTs
3. Lateral
* Cuboid and 4th and 5th MT
* Most mobile, acts as shock absorber
114
What are the physical examination findings in a Lisfranc injury?
[JAAOS 2017;25:469-479]
1. Difficulty WB
2. Swelling (typically dorsomedial)
3. Plantar ecchymosis
4. Pain with palpation of TMT joints
5. Pain with passive abduction of the midfoot while the transverse tarsal joint are stabilized
115
What are the recommended xrays to obtain in suspected Lisfranc joint injury?
[JAAOS 2017;25:469-479]
1. AP (with xray beam 15°off vertical plane)
2. Lateral
3. 30° oblique foot views
116
What radiographic features should be assessed to rule out a Lisfranc injury?
[JAAOS 2017;25:469-479]
1. Medial border of 2nd MT should align with the medial border of the middle cuneiform (AP view)
2. Medial border of 4th MT should align with the medial border of the cuboid (oblique view)
3. Dorsal and plantar cortices of MT should align with the cuneiforms and cuboid (lateral)
4. Widening \>2mm between 1st MT/medial cuneiform and 2nd MT (compared to contralateral side)
5. \>2mm joint subluxation of the TMT joint
6. Any dorsal displacement of the MT (lateral view)
7. Fleck sign
* Avulsion fracture off the base of the 2nd MT or medial cuneiform
117
What are they simplified adiographic signs of Lisfranc injury?
1. Fleck sign (AP view)
2. Medial side of 2nd MT should line up with medial aspect of middle cuneiform
3. Widening between base of 1st and 2nd MT
4. Dorsal subluxation of 2nd MT (lateral view)
5. Medial side of 4th MT should line up with medial aspect of cuboid (oblique view)
118
What xrays can be taken to investigate suspected Lisfranc injury if initial xrays are negative?
[JAAOS 2017;25:469-479]
1. WB radiographs including AP with both feet on the same cassette
2. Pronation-abduction stress radiograph
119
How do you classify TMT joint complex injuries?
[JAAOS 2017;25:469-479]
1. Myerson
* TYPE A – total incongruity
* Involves displacement of all five metatarsals +/- fracture at the base of the second metatarsal
* Usual displacement is lateral or dorsolateral
* These injuries are homolateral
* TYPE B – partial incongruity
* One or more articulations remain intact
* Type B1
* Partial incongruity with medial dislocation
* Type B2
* Partial incongruity with lateral dislocation
* First tarsometatarsal joint may be involved
* TYPE C – divergent
* Type C1 – partial displacement
* Type C2 – total displacement
2. Nunley and Vertullo
* Classification system to guide treatment of low-energy, athletic injury patterns
* Stage I
* Pain isolated to the TMT joint complex
* Normal WB radiographs
* Increased uptake on bone scan
* Stage II
* 1-5 mm of widening between the first and second MTs on WB views without evidence of height loss in the longitudinal arch
* Stage III
* \>5 mm of widening of the intermetatarsal space as well as longitudinal arch collapse
120
What are the indications for nonoperative management of Lisfranc injuries?
[JAAOS 2017;25:469-479]
1. Stable injury patterns
2. Patients unable to tolerate surgery
121
What are the principles of surgical management of Lisfranc injuries?
[JAAOS 2017;25:469-479]
1. Preoperatively perform closed reduction if midfoot dislocation exists
2. Delay until soft tissue is appropriate
3. Rigid fixation for medial and middle columns
* Flexible and temporary fixation for lateral column
4. If equinus contracture present, perform gastrocnemius recession when major contracture found
5. Exposure, reduction, and fixation generally proceed from proximal to distal and from medial to lateral
6. Dual incisions for 3-column injuries
* Dorsomedial – centred between 1st and 2nd MT
* Mobilize dorsalis pedis artery and deep peroneal nerve laterally
* Interval between EHL and EHB commonly used
* Dorsolateral – centred over 4th MT
* Common extensor tendons mobilized medially
* EHB split in line with fibres
7. Anatomic reduction under direct visualization
* Reduce intercuneiform joints first then TMT joints
8. If cuboid is impacted restore the length of the lateral column
9. Postoperative nonWB for 8 weeks in cast
* Then walking boot
* Then supportive shoe wear and arch support by 3 months
122
What is the role of arthrodesis in Lisfranc injuries?
[JAAOS 2017;25:469-479]
Controversial
* May have a role in purely ligamentous injuries (tend to have increased posttraumatic arthritis)
* May also consider in delayed presentations [CORR trauma]
* \*\*\*Note: Fusion should not involve the lateral column [Tornetta]
123
When comparing ORIF vs. Arthrodesis for the management of Lisfranc injuries what is the main difference based on the most recent systematic review and meta-analysis?
[CORR 2016 Jun; 474(6): 1445–1452.]
1. ORIF has a higher rate of hardware removal
2. No difference in anatomical reduction, patient reported outcomes or need for revision surgery
NOTE: no new trials performed since 2012
124
What are the 3 zones of the proximal 5th MT?
[JAAOS 2009;17:458-464]
Zone 1 – tuberosity
Zone 2 – metaphyseal-diaphyseal junction (Jones)
Zone 3 – diaphyseal stress
125
What is the Torg classification of proximal 5th MT fractures based on radiographic appearance?
[JAAOS 2009;17:458-464]
Type I
* Fracture extending from the lateral tuberosity to the metatarsocuboid joint (most common)
Type II
* Fracture extending from the lateral tuberosity distally to the 4th-5th intermetatarsal joint medially (Jones)
Type III
* Fracture distal to the 4th-5th intermetatarsal joint
126
What are the mechanisms of injury for Type I-III injuries?
[JAAOS 2009;17:458-464]
Type I – foot inversion
* Peroneus brevis and lateral band of the plantar fascia avulse
Type II – forefoot adduction with foot in plantarflexion
Type III – overuse
127
What is the Torg classification for age of fracture based on radiographic appearance?
[JAAOS 2009;17:458-464]
Type I – Acute
* Narrow fracture line
* No intramedullary sclerosis
Type II – Delayed
* Widened fracture line with intramedullary sclerosis
Type III – Nonunion
* Medullary canal obliterated
128
What is the blood supply of the proximal 5th metatarsal?
[JAAOS 2009;17:458-464]
1. Metaphyseal arteries – enter proximally
2. Nutrient artery – enters diaphysis
3. Periosteal arteries - peripheral
4. Watershed area at the metaphyseal-diaphyseal junction
* Zone II - Jones Fracture
129
What are the indications for nonoperative management of fifth metatarsal fractures?
[World J Orthop 2016 18;7(12):793-800]
Nondisplaced Type I and II (in nonathlete)
130
What is the nonoperative management for a type I and type II fracture of the base of the 5th metatarsal?
[World J Orthop 2016 18;7(12):793-800]
Type I
* Protected full WB
* Aircast, short walking cast, rigid shoe
Type II
* nonWB in short leg cast 6-8 weeks
131
What are the surgical options for 5th metatarsal fractures based on type?
[World J Orthop 2016 18;7(12):793-800]
Type I
* Intramedullary screw
* K-wire
* Tension band
Type II and III
* Intramedullary screw
Nonunions
* Open curettage followed by intramedullary screw
132
What are the indications for operative intervention for 5th metatarsal fracutres?
[World J Orthop 2016 18;7(12):793-800]
Type I
* Displaced \>3mm or comminuted or \>2mm step at the metatarsocuboid joint
Type II
* Displaced
* Acutely in athletes (even if undisplaced)
* Early return to sport, faster union
* Delayed union (relative)
Type III
* All
\*\*\*Any symptomatic nonunion
133
What are the pearls and pitfalls of intramedullary screw fixation of 5th metatarsal fractures?
[JAAOS 2009;17:458-464]
PEARLS
* The incision should be made proximal to the fifth metatarsal base between the peroneus brevis and longus tendons
* The guidewire should be started in a high and inside position at the base of the fifth metatarsal
* The selected screw size must allow adequate endosteal bite of the screw threads
* The screw threads must cross the fracture for compression to occur at the fracture site
* The screw should not be excessively long
* I.e. Do not straighten the fifth metatarsal
PITFALLS
* An improper screw angle may cause gapping at the fracture site
* A screw that is too short will not compress the fracture because the threads will not completely cross the fracture site
* A screw that is too long placed in curved bone may cause gapping at the fracture site
* A screw that is too large in diameter may cause further fracture, cortical compromise, and/or stress shielding
