Foot

Foot Intro

• Three regions:
  • 1. Hindfoot (talus and calcaneous)
  • 2. Midfoot (navicular, cuneiform, and cuboid)
  • 3. Forefoot (metatarsals and phalanges)
• Foot Fractures result from:
  • 1. Direct Trauma
  • 2. Indirect Trauma
  • 3. Overuse
• Foot Anatomy:
• 

• Imaging
  • AP, (medial two TMT joints)
  • Oblique (lateral three TMT joints)
  • Lateral views (calcaneal)
• Sessamoid bones - Bones within tendons over joints (such as the patella).  Help protect tendon from joint, and lifts the tendon from the joint space.
• Secondary ossification centers - many in foot.

Calcaneus

• Most common tarsal injury (60% of tarsal injuries)
• Anatomy:
  • Forms bottom of subtalar joint, which has three articular surfaces:
    • Anterior, middle, and posterior.
  • Sustentaculum talus is medial extension of calcaneus that supports anterior and middle articular facets.
  • Peroneal tubercle: on lateral surface provides a groove for peroneal tendons and groove where peroneal retinaculum attaches.
  • 75% of calcaneal fractures are intra-articular, 75% depressed.
• Mechanism: Usually fall from height, often >8 feet.
• Complciations:
  • Compartment Syndrome
  • Fracture blisters (clear or blood-filled), may delay surgery to avoid high rates of infection.
  • Sural nerve entrapment.
  • Based on mechanism:
    • Thoracolumbar Compression Fractures. (10%)
    • Compartment syndrome (10%)
• Imaging:
  • Easy to see on AP/oblique/lateral views.
  • Bohler's Angle (20-40° normal)

    • Bohler's Angle (Normal: 20-40°) Calculated by measuring angle between two lines 1. From superior margin of posterior calcaneal tuberosity (back-top tip) to superior tip of posterior facet (back-top tip of ST joint). 2. From superior tip of anterior facet (front-top of ST joint) to superior tip of posterior facet (back-top of ST joint).

    • If angle is <20°:
      • 1. Depressed fracture present even if not seen on Xray
      • 2. Worse outcome regardless of intervention.
      • Bohler angle can be normal even with bad fractures, so it does not rule-out anything.
  • Can do Harris view to see extent of intra-articular involvement and degree of depression.
    • Shoot obliquely across plantar heel of dorsiflexed foot.
  • CT: Gold standard, can see extent of damage (xrays can't see extent in half cases)
    • Do CT if surgery needed.
• Treatment:
  • ALL:
    • Ice, elevate (decreases soft-tissue injury, decrease blisters)
    • Immobilize: Bulky compression dressing + posterior splint.
    • Non-weight bearing: Give crutches to prevent further bone+soft tissue injury.
      • If intra-articular or displaced: non-wt bearing x6-8w.
      • If extra-articular: non-wt bearing x4-6w.
      • then gradual increase in activity.
    • Hydrothreapy
    • Surgery: Controversial.
      • Should consult ortho in all cases unless non-displaced, extra-articular
      • Surgery if compartment syndrome
      • Displaced intra-articular: controversial.  (can wait 7-10 days, especially if swelling)
      • If comminuted, displaced, depressed: need to re-establish joint congruity, so prob need surgery. (ORIF: often pins).
  • Admit if suspect compartment syndrome.
• SPECIFIC FRACTURES:
  • Anterior Process Fracture:  (15% of talar fractures)
    • Avulsion Fracture, secondary of abduction foot in plantarflexion.
    • Mechanism: Twisting foot.
    • Bifurcate ligament inserts into calcaneus and cuboid+navicular.
    • Tx:
      • ice, elevate, wt bear as tolerated.
      • Removal fracture boot 4-6wks.
    • 
  • Sustentaculum Tali Fracture:
    • Uncommon.  
    • Mechanism: axial compression of heel with inverted ankle.
    • Pain worse with inversion of foot or hyperextension of great toe.  (Flexor hallucis longus passes beneath sustentaculum tali).
    • Tx:
      • Non-displaced:
        • Cast, and non-wt bearing for 8wks.
        • Ortho referral.
        • Chronic pain common
      • Displaced: Emergency ortho referral + ORIF.  (Sx in 10 days after swelling better).
      • 
  • Lateral Calcaneal process and Peroneal Tubercle Fractures.
    • Tx symptomatic, soft support 4-6w.
    • 
  • Medial Calcaneal process fracturs:  Uncommon, look up
    • 
  • Calcaneal Tuberosity Fractures:
    • Avlusion by Achilles tendon.
    • Mechanism: Fall or jump landing on doris-flexed foot with knee extended.
    • ON Exam: weak plantarflexion, inability to walk, pain in this area.
    • Tx:
      • Non-displaced:
        • non-wt bearing cast in slight plantarflexion x6-8wks.
        • Ortho consult.
      • Displaced: Ortho ---> ORIF (especially if putting tension on soft-tissue).
    • 

Talus

• Uncommon <1% of all fractures.
• Difficult to visualize
• Anatomically three segments:
  • Head, neck body.
  • Held in place by ligaments, no muscle insertions.
  • Blood supply enters via deltoid ligament, talocalcaneal ligament, anterior capsul, and sinus tarsi.
• Fractures: Major vs. Minor
  • Major Fractures:
    • Involve head, neck or central portion of body.
    • Neck fractures divided into Hawkins Types:
      • Type I - nondisplaced
      • Type II - displacement w subluxation or displacement of subtalar joint.
      • Type III - Process displacement + dislocation from subtalar and ankle joint.
      • Type IV - Displaced from subtalar joint and talar head dislocated.
  • Minor Fractures:
    • Fractures of body of talus (include lateral process, posterior process, and osteochondral talar dome).
    • "Snowboarder's ankle": lateral process fractures (axial loading, dorsiflexion, eversion, ext rotation.
    • Posterior process: uncommon, hyperextension.
• Mechanism:
  • Neck Fractures: Acute dorsiflexion.
    • Called "Aviator's astragalus" b/c occured in WWII pilots after rudder forcibly dorsiflexed ankle when crashlanding planes after bombing missions.
  • Body Fractures: Acute hyperextension

• Treatment:
  • "Major" fractures:
    • Ice, elevate
    • Immobilize: crutches
    • Early consult.
    • Non-weight bearing cast for 6-8wks.
    • ORIF if talonavicular joint instability, displaced in articular step-off or later than 50% of articular surface.
    • Non-displaced: short-leg walking cast for 6wks followed by 3 weeks of partial wt bearing.
  • "Minor" fractures:
    • ice, elevation, immobilization in short-leg spint. (keep ankle in neural position).
    • Crutches + ortho referral.
    • OR if >2mm displaced.
• Complications:
  • Talar Head: Talonavicular OA or chondromalacia.
  • Talar neck: AVN, peroneal tendon dislocations, delayed union.

Midfoot (Navicular Cuboid and Cuneiforms)

• Rare, non-mobile segments.
• Sensitivy of xrays is 25-33% of detecting midfoot fractures

Lisfranc Joint Fracture-Dislocation

• Spectrum from stable sprain to unstable fracture dislocations.
• Lisfranc fracture-dislocations are rare (0.2% of all fractures), but high incidence of chronic pain and functional disability.
• 20% rate of misdiagnosis (one of the most common malpractice lawsuits against ER physicians).
• If not properly managed --> HIGH POTENTIAL OF DISABILITY
• Anatomy:
  • Lisfranc Joint: articulation of midfoot with metatarsals
    • Cuneiforms articulate with first three metatarsals
    • Cuboid articulates with last two metatarsals.
    • Ligaments:
      • TMT ligament (tarsometatarsal) binds each of the metatarsal bones to a bone of midfoot.
      • Transverse intermetatarsal ligament: binds proximal aspects of second through fifth metatarsals.  (strong ligament!)
      • Lisfranc ligament: Very strong ligament binding across from the 2nd metatarsal to medial cuneiform.
      • No ligament btwn 1st and 2nd metatarsals.
      • NOTE: 2nd metatarsal is bound by three ligaments, so usually fractures rather than dislocates.

    • NOTE: Fracture of base of 2nd metatarsal suggests a Lisfranc fracture-dislocation until proven otherwise!!!

    • 
• Classification (not prognostic!!!)
  • Classification based on whether or not all of the lisfranc joints disrupted (total/partial incongruity)
  • Direction of displacement is noted: Medial, lateral, dorsal, or plantar.
  • "Homolateral" dislocations are common (4 or 5 metatarsals moved to same direction)
  • "Divergent" dislocations occur usually between 1st and 2nd metatarsals (opposite directions) b/c weakest joint.
    • Direct force splits the groove btwn 1st and 2nd mt's. 
• Mechanism:
  • Usually MVA..
  • Direct force - or indirect via axial loading on plantarflexed foot.
  • High risk of compartment syndrome!
• Exam:
  • Tenderness over the joint.
  • Patient may be able to amulate!!  cannot exclude diagnosis.
  • Ecchymosis may be present on plantar aspect of foot.
  • Pain on passive dorsiflexion of toes suggest compartment syndrome.
• Imaging:
  • AP, oblique, and lateral radiographs.
  • AP better 1st and 2nd metatarsal.
    • 1. 1st metatarsal aligns with medial cuneiform.
    • 2. Medial borders of 2nd metatarsal and middle cuneiform aligned.
    • 3. Distance btwn bases of 1st and 2nd mtls should be <3mm.
  • Oblique better for others.
    • 4. Lateral borders of 3rd mtsl  and lateral cuneiform aligned.
    • 5. Medial borders of 4th mtsl and cuboid aligned.
  • Lateral
    • Evalute dorsal and plantar dislocation
    • 6. Dorsal surface of metatarsals is in line with respective tarsal.  Never disrupted.

    • Medial aspect of middle cuneiform and 2nd metatarsal align.  Any disruption of this is indicative of dislocation, which may have spontaneously reduced.

  • Standing Stress Views:
    • May be required.  Up to 10% of Lisfranc injuries cannot be seen without stress views.
    • Poorly tolerated due to pain.
  • CT is best!  25% seen on CT and not on xray.
  • 
• Complications:
  • 1. Fracture of base of 2nd metatarsal
  • 2. Avulsion fractures of tarsals and metatarsals.
  • 3. Cuboid, cuneiform, navicular injuries.
  • 4. Compartment syndrome.
  • Degenerative arthritis, chronic pain, etc..
• Tx:
  • Analgesics, ice, elevation, immobilization.
  • HIGH POTENTIAL OF DISABILITY
  • Even a mild sprain of the joint with normal radiographs should be kept non-wt bearing until further evaluation.
  • Fracture-dislocations ALMOST ALWAYS require ortho consult + operative repair.
    • If indicated, do surgery in 12-24hrs after injury, sometimes need to wait 7-10d for swelling to decr.
    • Closed reduction with cast will reduce, but not be stable enough. (need pins+screws).
  • Need Custom arch support for 12 months after. 
  • 90% success with good management.

Metatarsal Fractures

Toe Fractures

• Phalanx Fractures are most common in forefoot.
• Mechanism
  • Majority from direct blow. (heavy object dropped)
  • Some stubbing toe.
  • Abrupt abduction ("night walker's fracture").
• Tx:
  • Most non-displaced or minimally displaced
  • Dynamic splinting (use cotton padding btween affected toe and neighbour
    • Change splint every few days for 2-3weeks.
    • Subungual hematomas can be drained with electrocautery or 18G needle.
  • 1st Metatarsal:
    • Important in weight bearing and balance... consider referring.
      • Especially refer if fracture intra-articular and >25% joint space involved.
    • Can buddy tape, hard-sole shoe.  If painful, can do posterior splint.
    • Comminuted:  Need walking cast (dynamic splinting not enough immobilization)
  • If Displaced:
    • Reduce in ER.
      • Digital block.
      • Traction + Manipulate (use nail for rotational guidance).
      • Postreduction film.
• Sessamoids:
  • Two sessamoids (flexor hallucis brevis).
  • Often acute-on-chronic trauma.
  • Local pain on palpation.
  • Pain with phalanx extension.
  • Treat conservatively (orthotics, hard sole shoe... can do walking cast if extremely painful).
    • If all else fails surgically resect sessamoid.

Plantar Fasciitis

• 15% of foot problems.
• Typically 40-60yo, but earlier in runners (10% of runners).
• Presentation:
  • Pain on undersurface of heel on standing or walking, and relieved with rest.
  • Frequently patients note pain after a period of bed rest, lessens after some activity, then severe again after duration of weight bearing..
    • (can say worse in morning when gets up, then better w activity, then worse with more activity)
• Mechanism:
  • Infalmmatory and Degenerative condition at site of origin of plantar fascia (medial tuberosity of calcaneus).
  • Irritation of periosteum can cause bone spur.
  • Risk Factors:
    • Excessive walking/standing/running.
    • Obseity
    • Poorly cushioned footwear.
• Exam:
  • local tenderness at anteromedial surface of calcaneus where plantar fascia attaches.
  • Dorsiflexion of toes worsens pain.
  • Pain always anterior to heel, and may radiate to sole.
  • 1/3 bilateral:
    • If bilateral R/O rheumatoid arthritis, SLE, gout.
• Imaging:
  • Clinical diagnosis, often no need imaging.
  • Radiographs or bone scans done sometimes to R/O spurs and stress fractures.
    • (15-25% of pop-n have spurs, most are asymptomatic)
• Treatment:
  • Rest, ice for symptoms.
  • Physical therapy, stretching
    • Stretch Achilles tendon

      • Achilles Stretch Lean against wall, one foot 1foot away, the other foot next to wall with forefoot extended up the wall).  Hold position x10secs and repeat 3x.  Perform stretch up to 5x/day initially and then couple of times per day for recurrence.

  • Foot-wear: new shoes, arch support, orthotics, night splits,
    • Use heel pad (1/2 inch) + arch support to reduce plantar fascia stretch.
    • Can also tape.
      •  (Apply 2-inch tape with tension on plantar aspect of foot.  Tape extends from base of 5th metatarsal to head of 5th metatarsal.  Tape should be bow-strung in arch area.)
    • DO NOT walk bearfoot, and replace worn-out shoes.
  • Anti-infammatories, i.e. NSAIDs
  • Injections (if all fails, effective, but cause fat pad atrophy --> pain!)
  • Surgery (Fasciotomy or release if all else fails)
• 80% improve 12months, but early tx (within 6w) hastens recovery.

Soft Tissue Injury and Dislocations