1. Midfoot Fractures
Jenny Jefferis

2. What is a midfoot fracture?
Fracture of the midfoot involving the:
Tarsometatarsal joint (Lisfranc Fracture)
Cuneiforms
Tarsal navicular bone
Cuboid bone

3. What is a Lisfranc Fracture?
Between the tarsal and metatarsal bones
The 1st & 2nd metatarsal articulates with the medial cuneiforms and are the keystones of the foot
Supplies stability between the midfoot & forefoot during gait

4. Lisfranc Fracture
Frontal view of the foot shows fracture/ dislocation in the tarsometatarsal joint (Lisfranc's joint) with dislocations of the 1st through 5th metatarsals

5. Various fractures of the tarsal navicular bone include:
Cortical avulsions
Most common
Results from twisting forces on the mid foot
Fracture of the tuberosity
May involve the post. tibial tendon
Bony fractures
Stress fractures

6. Tarsal Navicular Fracture
Frequently have posttraumatic arthritis & discomfort in all phases of gait
Requires immobilization in a non-weight bearing short leg cast

7. Cuboid Fracture
Known as nutcracker fractures because the cuboid is cracked like a nut b/w the 5th metatarsal & the calcaneous as the forefoot is forced into abduction.

8. Cuneiform Fracture Uncommon Usually occur w/ high-energy injuries
Open reduction & internal fixation is recommended

9. Mechanism of Injury 3 common causes Twisting of the forefoot
Often occur during vehicle accidents when the foot is abducted
Axial loading of a fixed foot
Occurs when falling on an extremely dorsiflexed foot or axial loading from body weight, stepping off a curb
Crushing
To the dorsum of the foot
Usually in industrial accidents
Clinician should be aware of compartment syndrome & injury to the dorsal pedis artery

10. Treatment Goals Alignment- Restoring the alignment with the cuneiforms
-Important for normal weight bearing
-Load distribution of the foot
-To maintain the medial arch of the foot
Restoring the length & alignment of:
cuneiforms
cuboid
navicular

11. Treatment Goals Stability Stable fixation of the navicular & cuboid
Allows effective transfer of weight from the hind foot
Helps with eversion & inversion of the subtalar jt.
A stable reconstruction of the Lisfranc joint
Important in maintaining the medial arch of the foot & a pn free and secure gait

12. Range of Motion Motion Normal Functional Ankle Plantar Flexion 45°
20 °
Ankle Dorsiflexion
20-25 °
10 °
Foot Inversion
35 °
Foot Eversion
25 °

13. Muscle Strength Invertors Evertors Dorsiflexors Plantar Flexors
Tibialis Anterior
Tibialis Posterior
Evertors
Peroneus Longus
Peroneus Brevis
Dorsiflexors
Toe extensors
Plantar Flexors
Gastrocnemius
Soleus
Peroneous Longus weakness
can result from severe dislocations
of the Lisfranc Fracture because
this muscle inserts on the 1st
metatarsal & 1st cuneiform

14. Time of Bone Healing Tarsometatarsal or Lisfranc Fracture
8-10 weeks
Tarsal Navicular
6-10 weeks
Cuboid & Cuneiform Fracture

15. Duration of Rehabilitation
Tarsometatarsal or Lisfranc Fracture
8 weeks- 4 months
Tarsal Navicular
Acute Fx:6 wks- 4 months
Delayed union, nonunion, or stress fx: 6 wks- 4 months
Cuboid & Cuneiform Fracture
6 wks- 4 months

16. Treatment Methods Tarsometatarsal or Lisfranc Fx: Cast:
Biomechanics: stress-sharing device
Mode of Bone Healing: Secondary, with callus formation
Indications: May be treated w/ a short leg cast for 6 wks. May bear weight when pn free.

17. Treatment Methods Open Reduction & Internal Fixation
Biomechanics: stress-shielding device w/ screw fixation
Mode of healing: Primary, w/ rigid fixation
Indications: Pt placed in a weight bearing cast for 6 wks. Unprotected weigh bearing is not recommended until screws are removed at least wks after surgery.

18. Treatment Methods Closed Reduction & Percutaneous Pinning
Biomechanics: Stress-sharing device w/ pin fixation
Mode of bone healing: Secondary, w/ callus formation
Indications: Kirschner-wire fixation. Placed in a non-weight bearing short leg cast after fixation. Wires removed at 6 wks, followed by protective weight bearing.

19. Treatment Methods Tarsal Navicular Fx Cast
Biomechanics: stress-sharing device
Mode of bone healing: Secondary, w/ callus formation
Indications: May be placed in a short leg cast.
Cortical avulsion fx: short leg walking cast, 4-6 wks.
Tuberosity fx: Short leg walking cast, 4-6 wks.

20. Treatment Methods Open Reduction & Internal Fixation
Biomechanics: Stress-shielding device w/ rigid fixation
Mode of bone healing: Primary, w/out callus formation
Indications: To avoid severe deformity & arthritis, must be treated w/ reduction & rigid fixation

21. Treatment Methods Cuboid & Cuneiform Fx Cast
Biomechanics: Stress-sharing device
Mode of bone healing: Secondary w/ minimum callus formation
Indications:
Cuboids: closed in a weight bearing cast
Cuneiforms: short leg cast, immobilized because of ligamentous damage

22. Treatment Methods Open Reduction Internal Fixation
Biomechanics: stress-shielding device
Mode of bone healing: primary, w/ rigid fixation
Indications:
open reduction & internal fixation for any amount of displacement, followed by a 6 wk. period of non-weight bearing.

23. Special Considerations of the Fx
Age
Joint stiffness particularly w/ navicular fx’s
Active Pts. Also are probe to jt. Stiffness w/ a navicular fx
Articular Involvement
Posttraumatic arthritis & fusion
Limited pronation & supination
Location or possible
Open Fractures
Damage to the dorsal pedis artery
Open fx must undergo irrigation, debridement, & intrevenous antibiotics
Always a possibility of compartment syndrome
Tendon & Ligament Injuries
Extensor tendons should be inspected for possible damage

24. Gait Stance Phase Heel Strike Foot-Flat Mid-Stance Push-Off
60% of gait cycle
Heel Strike
↑ pn from inversion to eversion
Foot-Flat
Painful b/c of injured bones of the medial arch
Mid-Stance
Painful as foot is moving from neutral to eversion
Push-Off
Pt may limit plantar flexion
Cycle is shortened
Swing Phase
40% of gait cycle
Not affected by any of these fxs b/c foot is not in contact w/ ground