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Midfoot Fractures Jenny Jefferis. What is a midfoot fracture? Fracture of the midfoot involving the: Tarsometatarsal joint (Lisfranc Fracture) Cuneiforms.

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Presentation on theme: "Midfoot Fractures Jenny Jefferis. What is a midfoot fracture? Fracture of the midfoot involving the: Tarsometatarsal joint (Lisfranc Fracture) Cuneiforms."— Presentation transcript:

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 1 st & 2 nd 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 1 st through 5 th 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 5 th 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 MotionNormalFunctional Ankle Plantar Flexion 45°20 ° Ankle Dorsiflexion °10 ° Foot Inversion35 °10 ° Foot Eversion25 °10 °

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

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

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 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

25 SI SI eG9hc344&feature=related eG9hc344&feature=related cast/ cast/


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