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SORE FEET

Dr Dane Horsfall

+Overview

Common fractures Midfoot Calcaneus 5Th Metatarsal

Cases

Easily missed injuries

Classification

+Case: 19yoM with painful R foot

Waterskiing accident - 3/7 ago - fell at high speed, pain since in R midfoot and unable to wt bear

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+Diagnosis

Widened gap at base of 1st/2nd Metatarsals with avulsion # of Lisfranc Ligament

Other Ix ?

Mitch Clark

+CT

+Progress

Mx Backslab, elevate-high risk compartment Sx

Ortho ref - seen in rooms 2/7 later

Admitted 11/7 later for ORIF 2x screws inserted, 6/52 non wt bearing in backslab

+LisFranc

Jacques Lisfranc de St Martin 1790-1847 French Surgeon/Gynae described injury 1815 after War of the 6th Coalition-falls from horses

The Lisfranc joint 5 tarso-metatarsal joints.

The Lisfranc ligament from medial cuneiform to base 2nd MT

LisFranc injuries Lig rupture Lig Avulsion Subluxation/Dislocation-assoc # MT

up to 20% are Lisfranc joint injuries missed

+Diagnosis

Mechanism-rotation, twisting, fall off horse, severe axial load- MCA, fall

Point tenderness over midfoot

Plantar ecchymosis sign

Wt bearing xrays

+Types

LisFranc -Ligament rupture +/- Avulsion +/- #’s

+Xray Gap >1mm btw bases 1st/2nd MT MT

+Calcaneal Fractures

Fall from height onto heels-axial load

Associated injuries other calcaneal # spinal wedge # pelvis

+Bohler’s Angle

Intersection of 2 lines Line from post articular

surface calcaneus to anterior articular process of calc

Post art process to sup angle of calc tuberosity

Normal 20-40° Abnormal if < 20°

+Calcaneal #

Image with CT-often worse # than appears on plain films-ref all to ortho

Calcaneal # without extension into subtalat jt and minimal displacement-can consider conservative Mx-watch for achilles tendon causing further displacement of #

If significant displacement and/or involvement Subtalar joint=ORIF

+Horizontal #

2 types Most common-post sup angle of

calc without achilles tendon insertion involvement “beak” # – from direct trauma eg kick

Avuslion # of achilles tendon from sudden calf muscle contraction

Thompson Test http://www.youtube.com/watch?v=AmDi08rlR3I

Mx Ortho ref - ORIF

+# Base 5th MT Jones or not?

Jones fracture = transverse # of proximal diaphysis of 5th MT, 10-20mm from the proximal end. Sir Robert Jones 1902 while dancing

“Pseudo Jones” = Avulsion # of the tuberosity of the base of 5th MT Most common lower limb # From forceful inversion (“sprained

ankle”)-Peroneus Brevis “sprained ankle” palp base 5th MT-

Ottawa foot rules

+Golden Rule:

If fracture enters or distal to the intermetatarsal joint = Jones fracture

If it enters cubo-metatarsal joint = Pseudo Jones/Avulsion

+Why differentiate?

Jones high non-union rate Rx due to

poor blood supply and tension from tendons

Rx - non wt bearing cast 6/52

Pseudo Jones Cast shoe/CAM walker 4/52

+Jones or Pseudo? 19yo Basketballer –Inversion injury

+Jones or Pseudo?

+Jones or Pseudo? 39yoM fell off chair

+References

Emedicine -Lisfranc

Tintinalli et al, Emergency Medicine

Max Esser and his book-Practical Fracture Management, R McRae, Max Esser

Wheeless Textbook of Orthopaedics online