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

Case 35M working on roof, falls, lands like a cat c/o bilat heel pain and back pain

Case

Calcaneus Fracture

Calcaneus fractures apex of anterior process apex of posterior facet Posterior tuberosity

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 28F, morbidly obese, caught toes as going down stairs Fell with foot in fixed position - forced plantar flexion

Case

Lisfranc cuboid cuneiforms

Lisfranc

Imaging: –AP/Lat/Oblique –Wt bearing films for subtle/suspected injuries –May need bilat views for comparison

Lisfranc What does normal look like? –MT 1-4 line up with medial edge of tarsal articulations (AP/obl) –MT 2 lines up with medail edge of middle cuneiform (AP/obl) –Doral alignment of tarsals and MT (lat)

Lisfranc What does abnormal look like? –Widening between MT 1-2 or 2-3 –MT2 base # (fleck sign) –Cuboid # –Cuneiform #

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….

Practice…

Practice….