My foot hurts….

Heather Patterson PGY-2

Emergency Medicine

May 31, 2007

Objectives

• Review relevant foot boney anatomy• Brief discussion about 3 foot fractures• Practise!

Anatomy

Anatomy

Case

• 35M working on roof, falls, lands like a cat

• c/o bilat heel pain and back pain

Case

Case

Calcaneus Fracture

Calcaneus fractures

apex ofanterior process

apex of posterior facet

Posteriortuberosity

Calcaneus Fracture

• Mechanism:– High energy axial load

• Intra or extraarticular

• Associations:– 7% bilateral– 10% spine compression #– 25% other LE injury

Calcaneus Fracture

• Imaging:– Standard AP/Lat foot and ankle views– Axial– +/- CT

• Important distinctions:– Involvement of subtalar joint– Depression of posterior facet

Calcaneus Fracture

• Ortho:– Treatment patterns vary– Intraarticular and comminuted fractures must

be seen

• Outcomes:– Poor outcomes– >50% have loss of ROM, chronic pain, and

functional disability

Case

• 32M fell and landed with pointed toes

Case

Talar fractures

• Anatomy:– 7 articular

surfaces (60% of surface)

– Regions:• Body • Neck • Head

Talar fractures

• Minor talar fractures:

– HEAD AND NECK:• Avulsion and chip

fractures of superior surface

– BODY:• Lateral, medial,

posterior body AND osteochondral of talar dome

• Require immobilization and referral to ortho for f/u

Talar fractures

• Talar neck fractures– 50% of major talar

injuries.

– Mechanism:• extreme

dorsiflexion

– Hawkins classification

– Often associated fractures

Talar fractures

• Type 1: nondisplaced• Type 2: subtalar subluxation• Type 3: dislocation of the talar body (50% open #’s)

• Type 4: dislocation of the talar body & distraction of the

talonavicular joint.

Fracture type influences management & prognosis

Talar fractures

• Talar body fractures

– 23% of all talar fractures

• Ie posterior or lateral process fracture

– Major talar body fractures are uncommon

• usually axial loading

Talar fractures

• Talar head fractures– Uncommon (5-10%)

– Compression transmitted through the talonavicular joint applied on a plantarflexed foot

Talar fractures

• Management:– Major fractures

require ortho consult

• Outcomes:– Risk of AVN, OA, and

chronic pain

Case

• 18F playing soccer, tripped and twisted foot

• Not sure of how she twisted/landed

Case

Navicular Fracture

• Classification:– Dorsal avulsion

• >50% of navicular #s • Eversion injury • Associated with deltoid

ligament injury• Minimal articular

involvement

– Tuberosity Fracture

• Eversion injury• Associated with

posterior tibialis tendon avulsion

Navicular Fracture

• Classification:– Body Fracture

• Rare• Axial loading• Comminuted,

intraarticular

Navicular Fracture

• Clinical– Pain on palpation– +/- pain on passive

eversion or active inversion

• Imaging– Standard foot views– +/- bone scan

Navicular Fracture

• Why do we care?– Significant risk of AVN

• Management:– Outpatient Ortho:

• Dorsal avulsion and tuberosity # with minimal articular involvement

• Immobilize 4-6 wks

– ED Ortho consult• Body#, displaced #, >20% of articular

surface involved

Practice….

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