wai Reamstuchon of He Ket + Anke ST Hee son Introduction The general goals of fracture treutment that were defined in the AO Manual of Internal Fixation: re now widely ac- cepted by the orthopedic community. Simply stated. the pri- mary goal of treatment is “rapid recovery of the injured limb,” and although this objectise seems obvious today. it ‘was not always the case. Long before the AO was founded. the so-called British school of fracture treatment advocated a philosophy de- scribed by Watson-Jones.” He recommended immobiliza- tion of a fracture, as well asthe joints above and below the fracture, and prolonged uninterrupted rest until the fracture united. Following these guidelines. radial and ulnar frac- tures were treated in a long-arm cast. tibial fractures were immobilized in a long-leg bent-knee cast. and femoral frac- tures were treated by spica casting. In practice. this ap- proach worked quite well in children. whose bones heal rapidly and whose soft tissues rehabilitate easily. In adults, however. prolonged casting often resulted in deformity. muscle atrophy, joint stiffness. and chronic edema. Collec- these complications became known as “fracture dis- cease.” Symptoms of fracture disease are more prominent in the lower extremity. where edems and stiffness are aggra- vvated by a dependent position und poor venous and lym- phatic circulation, ‘Concerned with these problems. :he AO group borrowed ideas from Danis, Lambotte. Kiintscher. Smith-Peterson, Haye-Groves*’, and others. and in the late 1950s they de- veloped a different approach to iracture care. The new pl losophy unified all aspects of fracture care (technique, in- strumentation, basic research, teaching. and documentation) by a common goal—rapid funcsional recovery of limbs free of fracture disease. Four means were identified by which to accomplish this end: 1. Anatomic reduction of all ractures. especially intraartic- ular fractures, to promote anatomic union: 2. Atraumatic soft-tissue techniques to preserve blood sup- ply going to bony fragments and soft tissues: 3. Stable internal fixation that is strong enough to withstand local biomechanical stresses during rehabilitation, and 4. Early mobilization of muscles und adjacent joints to pre~ vent stiffness during bony heali \ ‘These principles should have been applied to the foot with- ‘oui delay but, until recently, even the AO did not strongly ad~ vvocate this concept in that area. I think the reason why trauma surgeons, who introduced sophisticated open reduc tion and internal fixation techniques to the rest of the mus- cculoskeletal system, neglected the foot is that basic anatomy, biomechanics, and function ofthe foot were not well taught surgical training programs. ‘The foot is an extremely complex structure. It contains more than 28 bones, in addition to countless ligaments, Joints, and muscles, and every structure interacts with the ‘others in the course of a normal gait cycle. Ihave divided the joints in the foot into three types: those that are essential for ‘normal function, those that are nonessential but useful, and those that are unnecessary (see Tables 1.1—1.3). As the foot evolved to support bipedal gait, many joints, particularly those in the midfoot, became nearly immobile in order to provide stability. These are the joints I call unnecessary, and they can be fused with litte or no loss of function. The literature regarding the foot is extensive, yet it can also be confusing, Sarrafian’ has written an extraordinarily detailed account describing the foot’s anatomy and biome- chanical functions. Others, including Young. Kicner. Lapidus, and Morton™'?, have described specific pathologi- cal conditions and lent their names to operations devised to correct them. No one, however, has provided an overview in which the functional anatomy of the entire foot is analyzed and related to treatment recommendations. Many different types of problems can occur in the foot. The origins of some conditions, such as instability of the first metatarsal or contraction of the gastrocnemius. may be atavistic: others can be caused by overuse or overload. muscle imbalance, arthritides, trauma, or congenital anomalies. When treating patients with foot dysfunction, a surgeon must have a general understanding of normal foot function, the causes of dysfunction, and appropriate man- agement of specific problems in order to make sense of the hundreds of treatment regimens, both operative and nonop- erative, that are available. In attempting to summarize these various opinions, observations. and ideas for myself, Ihave developed an overall concept that has proved very helpful to me.Introduction Knowledge of the Foot's basic functional anatomy facili- tates classification and treatment of dysfunction. The human foot has evolved from an anthropoid foot to accommodate bipedal gait. It provides us with instant feedback regarding ‘our position in space while adapting itself to sloping surfaces and furnishing support and propulsion, When it is function- ing normally. the foot is capable of very diverse Functions: it can enable a tiny gymnast to perform on a balance beam. a ‘marathon runner to run for hours. and a 6'10" basketball player to leap for a slam dunk The physical demands of bipedal gait are satisfied in a number of ways. Weight bearing in most four-legged animals ‘occurs distal to the heel sich in quadrupeds isan elongated. nnon-weight-bearing structure that functions as a lever fora tion by the triceps surae. An important divergence from a quadruped foot is seen in the ankle of an anthropoid foot, which has dropped to the sround and enables the calcaneus to” bear weight along with the forefoot. As a result, the foot has abroad stable surface capable of greater weight bearing. The ‘calcaneus still functions as a lever during propulsion as con- tact with the ground and weight bearing ae transferred tothe distal ends of the metatarsals and toes. The evolutionary changes responsible for bipedal gait have also altered the method by which forces exerted by gait are absorbed by the foot. A major development was rotation inthe leg, which allowed all the joints of the lower extrem- ity to move in the line of forward progression. With only two legs to support weight and several joints of the lower limb located on the ground during stance. human beings must have a mechanism for rotation inthe leg to alternate between cushioning and strong pushoff in the forefoot during gat. In biomechanical terms. this is called pronation and supination ‘with internal and external rotation ofthe leg. These motions are important factors to bear in mind when analyzing dys- function and choosing effective treatment. Because they are carried out primarily through the subtalar and talonavicular joints, these joints are perhaps the most essential articula- tions inthe foot. Bipedal gait is dependent upon normal function in several other structures in the foor, Lowering the calcaneus to the ground has necessitated creation of an arch called the medial ‘column, under the firstray. Shaped like a leaf spring, the me- dial arch serves two purposes, The first isto protect the point of entry of all neurovascular and tendinous structures, except the peroneus longus. going to the anterior foot and the toes. ‘The second is to cushion gait by lowering during pronation and rising and stiffening during supination. Supination and pronation (inversion and eversion) take place through the per- italar joints. These joints maintain stability and help the foot adapt to uneven surfaces by softening and stiffening the me- dial column during internal and external rotation ofthe leg. Flexion in the ankle is motored by the triceps surae. This mus- cle adapts the foot to surfaces tilted inthe line of progression and provides strong propulsion through the calcaneal and me- dial column lever arm, Mobility in the ankle, subtalar, and talonavicular joint is essential for bipedal gait, and treatment xvii of any foot problem should preserve the function of these joints if a all possible. Other joints along the medial column and in the midfoot, including the naviculocuneiform and the cuneiform-first metatarsal joins. are held in place very firmly by ligaments and motion here is unnecessary to foot function ‘The current function of the midfoot joints is to provide sta- bility and a solid attachment forthe base of the metatarsals. ‘The greatest difference between anthropoid and human feet is found in the forefoot. The first metatarsal in the hu- ‘man foot has migrated laterally to a position near and paral- lel tothe second metatarsal. Because its articulation withthe tarsus is rigid and no longer opposes the other metatarsals, the first metatarsal is incapable of grasping, Instead, its ma~ {or Function is to bear weight inthe forefoot and the anterior portion of the arched medial column. Adequate stability and length of the medial column, especially in relation to the length of the lateral column, is essential for transmitting ‘weight from the hindfoot tothe forefoot during pushoff. Although the toes are still motored by tendon attachments originally intended for grasping and which are nearly identi- cal to those in the fingers, they have assumed a different * function: to support weight along with the metatarsal heads. In order to carry out this new activity, the tarsometatarsal and interphalangeal joints have forfeited their inherent mo- bility and have become nonessential, or even unnecessary Muscles that had once motored the now unnecessary joints retain no essential purpose in thei origina positions and are expendable or available for transfer to augment or replace the action ofa dysfunctional muscle that fails to motor an es- sential joint. In the interphalangeal joints, for example, the flexor digitorum communis can be transferred to augment the function of the posterior tibial tendon, which controls midfoot position in the essential talonavicular joint. ‘This book is organized into three sections. Trawma is dis cussed first and each chapter in this section is self-contained, ‘The next section, Reconstruction, is organized differently. Each chapter in this section begins with a discussion of the pathcanatomy, pathological biomechanics, and treatment of a given condition. Ifthe treatment of a specific problem is unique, itis described in detail ifthe technique can be ap- plied to correct other problems as well, itis described and il- lustrated in the third section, Atlas of Surgical Techniques Detailed descriptions of functional anatomy and biomechan- ies are presented in appropriate sections discussing specific problems or operations. In all cases, I have attempted to ‘make clear the relevance of normal functional anatomy to specific pathological conditions and to explain the reasoning behind the proposed treatments References 1. Miler ME llgower M, Schneider Rt a. (E48), Manual o eral Fixation. Third Ed. Berlin: Springer-Verlag. 1991. 2 Watson-lones R. Fractures and Joint Injuries. Fourth ed. Edinburgh: Livingstone, 1957 3 Danis R. The aims of internal Fixation. Clin Orthop 138:23-25, 1979. ‘Translated by Perren SM from Theorie et Praioque de L’Ostéosyn- ‘heres, Pas Libris de L' Academie de Medicine, 168.ER 1 a Functional Anatomy of the Foot and Ankle The Forefoot In 1935 Dudley J. Morton published The Human Foot: Its Evolution, Physiology und Functional Disorders (1). When he wrote this book. Morton was associate professor of anatomy at the College of Physicians and Surgeons of Columbia University of New York. Much of Morton’s study was done at Yale University. and many of the subjects were his own students, Morton believed that to adequately man- age foot disorders. one should completely understand its functional anatomy and, by logical consequence. its func- tional disorders. Adding to this a knowledge of evolution, ‘comparative anatomy. and physiology (which today is called biomechanics). one would have a competent understanding Of the disorders that occur in the human foot. I could not agree more. Because he was not « physician and, specifically, not a foot surgeon. Morton had no particular ax to grind or a per- sonal operation to defend. He could simply look at his find- ings objectively. He did not recommend surgical treatment because he had no experience or expertise in that field. Mor- ton’s observations. however. are extremely pertinent for foot Surgeons today because technology is available to correct the anatomic and functional disorders that Morton very accurately idemtiied Morton made a number of keen observations. For exam- ple, he found that hypermobility in the first metatarsal seg- ‘ment. which he described as either the first metatarsal or the first metatarsal plus the ‘irst cuneiform bone. seemed to be a ‘major cause of dysfunction in the human foot. This included pain in the lesser metatarsals and excessive pronation, Mor- ton’s studies showed that as the human foot evolved toward ipedal gait. the first metatarsal became enlarged and was ixed parallel 10 the second metatarsal. Moreover, the two sesamoids in the first metatarsal each accepted the same amount of weight as each of the other lesser metatarsal heads. Morton maintained that there was an axis of balance in the foot that ran through the center of the hindfoot and midfoot and outward between the second and third metatarsals, Three of the weight-bearing points were located medial to this axis, and three were lateral. Morton demonstrated that little or no stance when the bony and ligamentous structures were prop- erly balanced. However, he rejected the beliefs of the two Prevailing schools of thought about foot structure. which as- cribed stability to either bone and ligaments or to muscles Morton maintained that integrity of all these structures was necessary for stability. He found thatthe medial muscles, in- luding the posterior tibial tendon and the toe flexors resist «excessive pronation and that contracture ofthe Achilles ten- don (tendo Ackillis,calcaneal tendon) aggravates pronation and metatarsal Paul W. Lapidus was a surgeon with a special interest in the foot who worked at the Hospital for Joint Diseases, In 1934, a year before the release of Morton’s book. Lapidus published a paper that described how he based his operation for hallux valgus on the correction of what he called metararsus primus varus (2). Lapidus believed that this was an atavistic trait and that it was the source of ‘most bunion deformities. Unfortunately his proposed oper- ation, consisting of stabilization of the first cuneiform— first metatarsal joint and capsulorrhaphy of the first ‘metatarsophalangeal joint. was unsuccessful. The princi- pal reason for failure was lack of adequate internal fixation to maintain the precise positioning that was needed. In spite of Lapidus” lack of evidence to corroborate his con- Viction, I believe that his analysis of this type of dysfunc- tion and the approach by which he attempted to correct it were correct. read Morton’s book after spending many years analyzing and trying to devise procedures to correct foot problems on ‘my own. I was gratified to leam that the philosophy I had formed about the functional anatomy of the foot was almost identical to his. Even more significant was that we came to the same conclusions from two very different backgrounds. In addition to Morton's and Lapidus’ works, a few other books should be required reading for all foot surgeons inter- ested in functional anatomy. These include The Joints of the Ankle and Human Walking by Inman and colleagues and Sarrafian's exhaustive text, Anatomy of the Foot and Ankle G-5) The present form of the human foot is similar to the anthropoid foot. Its basic anatomy is nearly identical tet the head ee... -Woop ae Portant divergence from hand anatomy is seen in the rela- tion between the first ray and the lesser rays. The first ray in the hand is mobile und opposes the lesser rays, whereas ‘mobility in the first ray of the foot is fixed in its current po- sition, Adapted for bipedal gait, the first metatarsal in the ‘oot lies parallel to the second. and it has formed an articu- lation with the tarsus that is almost as stable as those be- tween the tarsus and the third and fourth lesser tar- sometatarsal joints. As a result, the entire forefoot functions as a single unit during weight bearing. and the individual toes have little capability for grasping. Weight bearing, par- ticularly during late stance and pushoff. is shared propor- tionately by the metatarsul heads and the toes according to the amount of contact each has with the ground, Shared Midfoot Long peroneal tendon Hindfoot Long plantar igarene Figure 1.1. Acute Trauma and Fracturé Surgery weight bearing equalizes pressure on the soft tissues under the metatarsal heads and on the plantar skin of the toes un= der the distal phalanges. ‘The human forefoot contains 21 bones and more than 21 articulations (Fig. 1.1A; Tables 1.1 and 1.2), These include five metatarsals, two sesamoids under the head of the first ‘metatarsal, five proximal phalanges, four middle phalanges, five distal phalanges. five tarsometatarsal joints. nine inter. halangeal joints, five metatarsophalangeal joints, and two Sesamoid-metatarsal joints. Six weight-bearing surfaces are located at the metatarsophalangeal level (two sesamoids and four lesser metatarsal heads), and five weight-bearing surfaces are located under the distal phalanges in a normal foot, Ancerior sibial tendon Posterior ‘bial tendon 8 Ulustration shows dissociated hindfoo, midfoot. and forefoot (plantar view), A There is close ap- Proximation of the midfoot block of bones. the nearly parallel positions of the frst, second. and thind metatarcale and the relative length of the metatarsals. B The planta li ‘muscle attachments have been superimposed onto the bony ‘nertarsal and medial tasometatarsal joints, The slightly k First metatarsl is a residual ofits preevoluionary mobility igaments and the posterior tibial and peroneus longus Structure. They provide stability in the arch and to the less substantial ligamentous network atthe base of theictional Anatomy Forefoot Musculature The forefoot is the site of numerous muscle attachments, especially on the first and fifth rays (Table 1.3), Two impor- tant muscle activities in the forefoot ate plantar flexion ofthe first metatarsal by the peroneus longus through its aitach- ment on the plantar lateral proximal metaphysis and dorsi- flexion of the media! ray by the anterior tibialis through its attachment on the plantar medial proximal metaphysis ofthe first metatarsal. The peroneus longus and anterior tibialis are antagonists. When is unopposed. the peroneus longus pro- duces medial cavus or plantar flexion deformities in the frst fay and raises the media arch. An unopposed anterior tibial muscle elevates the first ray and flattens the arch, Next in importance among the muscle attachments on the proximal forefoot ure the peroneus brevis. which ataches to the base of the fifth metatarsal and the peroneus tetus. Both muscles are antagonists the posterior tibialis, The primary functions of the peroneus je i ae abduction ofthe forefoot and eversion ofthe entire foot. Approximately 10% of per- sons lack a peroneus tetius. When this muscle is present, it attaches dorsally onto the proximal fifth metatarsal and ele- Yates the lateral border of the foot 0 assist with ankle dors flexion. These four muscles—the peroneus longus, anterior tibialis. peroneus brevis, and peroneus tertius—contol the general attitude of the forefoot and its attachments to the midfoot. When the peroneus tertius is absent. the common toe extensors are sometimes recruited to dorsiflex and evert the lateral aspect of the foot, Marked extensor clawing can occur when the intrinsic muscles are overpowered. Most of the other muscles in the forefoot act across the metatar- sophalangeal joints. ‘The first metatarsal is much more complex than any of the lesser metatarsals. and muscle function across the first metatarsophalangeal joint is correspondingly more complex than itis in the lesser metatarsophalangeal joints. By virtue ofits size, the grea te bears one third or more of the weight of the body through 10 sesamoid bones. Medial and lateral short flexors act throuzh ‘he medial and lateral sesamoids. They attach tothe proximal metaphysis ofthe proximal pha- Janx and flex it over the “wad of the metatarsal, Together with the flexor hallucs iongus and its attachments to the dis- tal phalanx and the vista! first toe. the medial and lateral short flexors provide « sitong weight-bearing force during pushoff. The presence of adductor and abductor muscles is a resid ual of preevolutionary changes, when the great toe acted in- dependently and was capable of grasping. The abductor at- ‘aches medially. and the more complex adductor, which has two heads, attaches laterally through the lateral sesamoid bone and the conjoined tendon. Because the first metatarsal has evolved into a stable weight-bearing structure, adduction and abduction atthe metstarsophalangeal joint have become undesirable. Today these muscles merely counteract each other and stabilize the area te in near-axial alignment with the frst metatarsal CW Ar ga mh Bt 0 The short flexor-sesamoid complex ideally is centered un- der the first metatarsal head so that it can participate properly in weight bearing. A midline crista separates the plantar sur- face of the metatarsal head into two articulations and helps keep the sesamoids in place. Additional stabilization is pro- vided by the intermetatarsal and intersesamoidal ligaments, Which traverse the foot at the level of the metatarsal heads. Consequently, lateral dislocation of the sesamoids from the ‘metatarsal head is unlikely, although medial migration of the ‘metatarsal head from the sesamoidsis possible and can result in dissociation and abnormal weight bearing. This condition occurs when the tarsometatarsal joint is unable to resist medial angulation forces exerted on the fist metatarsal Muscles attaching into the great toe share similarities with ‘muscles attaching into the thumb, and not surprisingly mus- cle attachments in the lesser metatarsals are similar to those inthe fingers. The intrinsic muscles, including the interossei and the lumbricals, at in part through the dorsal hood at- fachments to plantarflex the proximal phalanx on the metatarsal head, They produce weak involuntary adduction and abduction. The short flexor divides and attaches medi- ally and laterally into the base of the second proximal pha- Janx to flex the proximal interphalangeal joins. The rela- tively powerful extrinsic long flexor attaches into the distal phalanx, flexing the distal interphalangeal joints and provid- ing some flexion power to the proximal interphalangeal Joints. This system of attachments is very effective for pow- erful grasping in the hand, but it is not desirable inthe foot. ‘The toes require strong flexion at the metatarsophalangeal joint and stability atthe proximal and distal interphalangeal joints during extension to share weight bearing with the ‘metatarsal heads, Differences in the magnitude of these op- Posing forces in the muscle attachments to the toes frequently result in intrinsic-minus clawing deformities. Extensor tendon function in the lesser toes is similar to that in the fingers. Intrinsic extensors in the great toe and the lesser toes attach to the dorsal base ofthe proximal phalanx and extend the metatarsophalangeal joint. A powerful long extrinsic extensor tendon attaches into the dorsal base of the ‘middle and distal phalanx. It extends the distal and middle interphalangeal joints primarily and the metatarsophalangeal Joints toa lesser extent. When the anterior tibialis or the per- ‘oneus tertius muscle is weak, this powerful long extensor is frequently recruited to dorsiflex the ankle. When it over- powers the intrinsic metatarsophalangeal flexor tendons, the long extensor tendon can produce an extensor clawing de- formity. The extensor hallucis longus also can be recruited in this manner and produces a cock-up deformity of the great toe when it overpowers the flexor brevis muscles. Plantar Fascia Another unique anatomic feature in the forefoot is the plantar fascia. The fascia originates on the anterior weight- bearing tubercle of the heel, spans the plantar aspect ofthe midfoot and the arch, and attaches to plantar skin under the——— 20 PART 4 toes and to the base of the proximal phalanges in the fore: foot. Together with the bony contour of the Foot. the strong inferior capsular ligaments of the midfoot joints. the tar sometatarsal joints, and the posterior tibial tendon, the plun- tar fascia helps to maintain the Shape of the medial arch. The peroneus longus provides dynamic flexion to the first ray ‘The plantar fascia tightens when the toes ate dorsiflexed and. increases the height of the arch by method similar to the ‘windlass mechanism, A cock-up deformity in the great toe consequently can plantarflex the first ry und produce a me- dial cavus deformity, conditions that .re sggravated by long Peroneal tendon overpull. These tiv conuitions ean uccur si= ‘multaneously. for example. in Char:-Marie-Tooth disease. in which the weak anterior tibialis cunt wdeguately oppose the powerful peroneus longus. Wiieit this occurs. the long extensor to the great toe is recruited ss substitute ankle dor- siflexor and produces pronounced plustar ‘lexion in the first ray and heavy callus or keratosis formation under the first ‘metatarsal head. First ray plantar ‘lesion produces a sec- ondary hindfoot varus deformity. Thus « typical foot with Charcot-Marie-Tooth disease hay i first ray cavus deformity and a varus deformity in the hinufoot. The lesser toe exten- sors work in a similar manner and can be recruited when the anterior tibial tendon or the peroneus tertius are weak. Re- cruitment of the lesser toe extensors produces dorsal clawing and secondary depression of the lesser metatarsal heads. Ligamentous Dysfunction The ligamentous attachments between the Forefoot and the ‘midfoot are discussed inthe section on the midfoot, but the Principal causes of ligamentous ls sfunction can bear men- tion here. In a normal foot. the strong plantar, imerosseous. and dorsal ligaments located atthe irst sree tarsometatarsal ints hold the joints nearly immobile Fig. |.1B), The appar- ent function of these ligaments is to help stabilize the longi tudinal arch ofthe foot and ‘© maintain the postion of the ‘metatarsal heads sothey can evenly dissibute weight bearing, This arrangement seems to deteriorate inthe presence of ex- cessive dorsal mobility inthe frst varsometatrsal joint and can result a functionally detivient ‘rs metatarsal, which is frequently malatigned in varus. One possible cause of this condition is absence of a proxinai ‘ntermetatarsal li between the first and second metatarsals The Lesser Metatarsals ‘The three middle rays are similar to each other except for the base of the second metatarsal. ‘hich is more rigtdly at- tached to the tarsus. For this reason. und because itis usually longer than the others. the second metatarsal frequently bears more than its share of weight under the metatarsal head. Originating at the highest point on the transverse tarsal arch. the second metatarsal is che longest metatarsal. Its length is critical to level the transverse arch ut the metatarsal heads during gait and to allow <1! “ye “eratarsal heads 10 as Acute Trauma and Fracture Surgery sume their share of weight bearing, Preservation of the trans- verse tarsal arch a the metatarsal head level would adversely affect gait in that only the medial and lateral metatarsal heads would then bear weight. The tarsometatarsal ligaments are fixed less rigidly in the fourth and, particularly, the fifth tarsometatarsal joints. As a result, these two metatarsals are more mobile, adapt more readily to iregular surfaces, and cushion weight bearing in the forefoot better then the first. second, and third ‘metatarsals. Some characteristics of the fifth metatarsal ‘make it uniquely different from the others. Like the first ‘metatarsal, itis bordered by an adjacent metatarsal only on one side, Muscle attachments to the fifth metatarsal include the abductor digiti quinti the atachments from two extrinsic ‘muscles, the peroneus brevis, and usually the peroneus ter- ‘ius. Because the arch on the lateral aspect of the foot is con- siderably lower, the entire length of the fifth ray, not just the area directly under the metatarsal head, makes contact with the ground during gait. An arched lateral column at the fifth ‘metatarsal Would serve no purpose because all the neurovas- cular structures and tendons going to the toes enter the sole of the foot on the medial aspect and are protected by the arched medial column. The only exception is the peroneus longus, which runs under the foot through a groove in the cuboid bone just behind the base of the fifth metatarsal. ‘The fifth toe is less functional than the others in that itis shorter and less well motored. The low angle of declination in the fifth metatarsal head also makes it less vulnerable t0 injury. However, the design of many shoes, particularly ‘women's shoes, does not provide adequate space in the toe box to accommodate the fifth toe and a common problem is extrinsic pressure on the toe because of its lateral position The fifth oe is expendable without loss of forefoot function. All these functional anatomic considerations must be kept in mind when teating patients with fractures and dislocations in the forefoot. Intrinsic Dysfunction The cause of forefoot dysfunction is not always obvious Damage tothe intrinsic tendons is clearly the cause of dys- function among patients with diabetic neuropathy, Charcot- Marie-Tooth disease. and inflammatory (cheumatoid)arthri- tis, but the origin of dysfunction can be obscure among Patients who seem otherwise healthy. It can stem from di verse causes, including hypermobility ofthe first metatarsal and subsequent transfer of excessive loads to the lesser metatarsals that produces traumatic synovitis in the lesser metatarsals that results in a condition similar to inflamma- tory arthritis. Frequently there is no obvious reason for dysfunction, The function ofthe intrinsic muscles in the foot i similar to tha of those in the hand. These muscles provide stability and allow flexion in the metatarsophalangeal joints and ex- tension inthe interphalangeal joints. In the hand. flexion of| the proximal and distal interphalangeal joints by the extrin-Functional Anatomy sie musculature produces gripping, In the foot. the extrinsic muscles work in unison with the intrinsic muscles to flex the metatarsophalanzeal joints. The action of the intrinsic muscles extends the proximal interphalangeal and distal interphalangeal joints and Mexes the metatarsophalangeal Joint, placing the toes in an optimal position for bearing Weight. Gait studies demonstrate that toes normally ase sume almost as much eight as the metatarsal heads dur. ing late stance. When the toes are functioning normally, they raise the metatarsal heaus slightly as they flex at the metatarsophalangeul joints. However. they function ec. centrically because they normally are acting most force. fully as the metatarsopitaiangeal joint is extending during late stance. Metatarsalgia is the most common symptom of patients seen in a foot clinic. and the causes and effects of intrinsic dysfunction must be cleuris understood and evaluated, When intrinsic dysfunction is vauned by diabetic neuropathy, early intrinsicplasty can prevent uiceration under the metatarsal heads and subsequent joss of the forefoot. When it is per- formed in conjunction ‘ith other remedial operations, in- trinsieplasty also can prevent deformities caused by condi tions such as rheumatoid arthritis. which would adversely affect gait and normal shoe wear, : Lesser metatarsal overload can be caused by first ray in- sufficiency stemming from instability in the first tar- Sometatarsal joint. Correction of this condition includes tar- sometatarsal arthrodesis for restoration of normal function to the great toe. butt is not limited to that. Although the objec- tive of treatment is to stabilize the first metatarsal and i crease the amount of weight bearing it will accept, intrinsic- Plasty also must be pertormed on the lesser metatarsals to Festore normal intrinsic muscle function and evenly distribute weight bearing A careful evaluation »t the entire foot is needed to de- termine the primary cause of claw toes, Clawing due to Simple intrinsic dysfunction must be differentiated from clawing caused by ther conditions. Extensor clawing of the toes is not al\say< reiaced to intrinsic dysfunction and can be caused by recruitment of the long toe extensors to assist a weak anterior “bial tendon oF to assist the per- oneus tertius with dorsiflexion, Flexor clawing is com- monly caused by one 2.0 types of disorders. The first is tenodesis result, 1 injury t0 the flexor tendons OF muscles or tenodes following a talar. ealeaneal, or tibial fracture, A deep posterior compartmental syndrome is typically responsible ‘or this type of clawing. The sec- ond type of flexor clawing occurs after recruitment of the long toe flexors to help the posterior tibial tendon support the arch, Extensor Clawing from Long Toe Extensor Recruitment A common cause ot snetatarsalgia is recruitment of the long extensor for ankle orsflexion, y long as the intrinsic CHAPTER 1 at ‘metatarsophalangeal flexors are strong, this is of litle con- Sequence. Permanent dysfunction in the toes occurs only in the presence of weak intrinsic muscles, a contracted or tight heel cord, or gastrocnemius equinus. These conditions stren- Uously engage the long extensor in a new activity and pre- Vent the tes from assuming a position parallel tothe ground during midstance and pushoff. This abnormal function of the {ong extensor overloads the metatarsal heads and eventually ‘causes metatarsalgia, The peroneus tertius is absent in a large number (5% to 10%) of persons with this syndrome. Absence of this tendon ‘not only explains why the recruitment occurs but also sug- ests an obvious solution to the problem. Whether the long. {oe extensor has been recruited for ankle dorsiflexion can be established during the physical examination by asking the patient to dorsiflex the foot strongly against the examiner's hhand, first with the toes flexed and then with the toes ex- tended. The diagnosis can be confirmed when normal dorsi- flexion is impossible with the toes flexed. The normal “anatomic course of the peroneus tertius is observed and pal- pated during these maneuvers to determine weakness or absence of the tendon, Absence of the peroneus tertius necessitates transfer of ‘one or more of the long extensor tendons to fascia or bone near the proximal end of the fifth metatarsal. ll the lesser toe extensors initially are transected about 2.0 cm Proximal to the metatarsophalangeal joint. The proximal ends of only one or two extensors are transferred, and the other two are severed higher inside their sheaths. Trans- fer of one or two tendon ends provides satisfactory re- sults because all the tendon ends are extensions of the same muscle. Chronic tightness of the extensor brevis muscles and ten- dons extends the metatarsophalangeal joint. To remedy this, each muscle and tendon and their attachments are sev «red atthe base ofthe toe and allowed to retract slightly be- fore they are sutured into the distal extensor longus ten- dons. This procedure results in weaker extension, but it restores adequate stability in the toes for performing rou- tine functions such as pulling on socks. The chief advan- ‘age of gaining additional length is that the toes can touch the ground again with the help of the toe flexor. Cases of long-standing dysfunction might necessitate classic intrin- sieplasty, that is. dorsal capsulotomy at the metatarsopha- 'angeal joint and a Girdlestone-type tendon transfer of the flexors, to supplement metatarsophalangeal joint flexion and eliminate clawing. In summary, extensor clawing can be managed by means of transfer ofthe extensor digitorum communis tothe base of the fifth metatarsal, transfer ofthe extensor brevis tendons to the distal extensor digitorum communis tendons, metatar- sophalangeal dorsal capsulotomy, and intrinsicplasty of the toes. These procedures restore normal function and appearance to claw toes with dorsal displacement. Recruitment of the extensor digitorum communis is less ‘obvious when the peroneus tertius is present but the treat-22 Parr io iment remains the same in all respeets but one, The ends of the extensor digitorum communis tendons that are trans- ferred ate inserted into the peroneus tertius rather than into fascia oF bone near the proximal half of the fifth metatarsal Recruitment ofthe extensor digitorum communis can be ag- gravated by a tight heel cord: if this isthe case, simultaneous percutaneous heel cord lengthening is indicated. Clawing is frequently a long-standing deformity among patients with rheumatoid arthritis and frequently progresses to dorsal dislocation of the toes. This disorder is managed by means of the same basic operation. The presence of marked dorsal contracture warrants shortening osteotomies of at least the second and third metatarsals to prevent the vessels and soft tissues from excessive stretching after the toes have been relocated. The toes may not straighten out completely ifthe skin underneath them has contracted. Re- section of the interphalangeal joints may be necessary t0 shorten the toes. This procedure can be performed on elderly or diabetic patients with neuropathy and paralysis of the intrinsic muscles to prevent development of ulcers under the metatarsal heads and possible degeneration leading t0 limb loss. The Midfoot Hindfoot, midfoot, and forefoot functions are closely inter- related. The five midfoot bones function a a single unit and form the Keystone of the medial arch ofthe foot. Motion in the medial column takes place primarily at the talonavicular joint, which is an essential joint. Very little motion takes place in the flat joints. namely. the naviculocuneiform joint and the articulations of the three medial cuneiform bones with the first three metatarsals. In a normal foot, the medial arch lowers between heel strike and foot flat to cushion and absorb impact. and it acts as a lea spring for the next phase of gait. When the arch lowers. it remains curved to protect the neurovascular and musculotendinous structures entering the foot on the medial aspect. The peroneus longus tendon is the only musculotendinous structure entering the plantar sur- face from the lateral aspect of the foot. It enters through a ‘groove in the cuboid bone where the corresponding lateral column is slightly arched. ‘The bones inthe midfoot block are further immobilized by riumerous short plantar and interosseous ligaments with lit tle excursion (Fig. 1.2). Slips from the posterior tibial ten- don, the only extrinsic muscle that motors this complex, at- tach to all five midfoot bones (Fig. 1.2B). The attachments zzoing 0 the two bones in the arched medial column. the na- ‘icular and the first cuneiform. are the most important, Evi- dence of sagging or gapping on the inferior aspect ofthe na viculocuneiform joint is widely recognized to be a patho- logic condition or a type of flatfoot deformity usually associated with asymptomatic arch. A breakin the tlar-tirst, ‘metatarsal angle that i as small as 5 degrees on anteroposte~ rior (AP) and lateral weight-bearing radiographic views can indicate a pathologie flatfoot deformity. The foot migrates, Acute Trauma and Fracture Surgery laterally away from the weight-bearing line of the tibia through the dome of the talus. This deformity is called lar- eral peritalar subluxation. In advanced stages. it becomes dorsolateral peritalar subluxation. These terms accurately define the site of the deformity as the midfoot rotates later- ally and dorsally in relation to the talus, which remains fixed in the ankle mortise. ‘The major articulations between the midfoot and the forefoot illustrate the close relation between anatomy and function. In a normal foot, the junctions between the cuneiform bones and the first. second. and third ‘metatarsals. especially the second, are immobile flat joint, ‘The articulation between the first cuneiform and the first ‘metatarsal retains some residual features of the thumb, namely, a deep, slightly beanlike shape. a weak inter- * metatarsal ligamentous attachment, and lack of a first-sec- fond intermetatarsal ligament distal to the joint. The first three metatarsals are almost perpendicular to the tar- somejatarsal joints, but the fourth and fifth metatarsals are positioned at different angles to the midline ofthe foot. The articulations with the fourth and fifth metatarsals are lo- cated lower in the transverse tarsal arch, and the angles of inclination of these metatarsals are smaller in relation to the arch of the lateral column. ‘The calcaneocuboid joint is less mobile than the subtalar or talonavicular joints. The cuboid bone, particularly, glides very little or not at all in a dorsal or lateral direction from a neutral position, The osseous shape of the cuboid and the short ligamentous attachments found there the cuboid to a plantar or medial direction from its neutral position on the anterior articular surface of the calcaneus. Mobility in the sagittal plane of the cuboid articulations with the fourth and fifth metatarsals cushions the lateral column, and it must be preserved for two important reasons. First, ‘motion in the cuboid is limited to one plane, and second, the lateral border isthe first area of contact with the ground dur- ing foot strike. In contrast, collapse of the lateral arch is not associated with any serious consequences because the arch does not protect any structures entering from the lateral aspect. Finally, the shape and stability of the joints in the tar- sometatarsal articulation help control distribution of weight across the metatarsal heads, Clearly, this function depends on the stability ofthe metatarsal base attachments, the length of the metatarsals. and their primary angles of inclination Because of the antagonistic forces of the anterior tibialis, the peroneus longus, and the plantar fascia. only the first metatarsal is capable of dynamic control of this postion, and even this is minimal in a normal foot Gastrocnemius Contracture or Equinus Deformity Major dysfunction in apparently normal feet can be at- tributed to either pathologic conditions or variations in nor- ‘mal anatomic features. The most common yet frequently un-Functional Anatomy cuAPTER 1 23 fan ana Figure 1.2. ilustation shows the deep ligaments joining the hindfoot tothe midfoot and the midfoot tothe forefoot. A: The deep ligaments shown with the earticulated foo bones are similar fo the ligamentous attachments depicted in ig. 1B. Numerous deep shor intrtarsal and tarsometatarsal ligament allow the mifoot nd the me- tial forefoot © move in unison around the talus through the pela joint. B: The long plantar ligament is pos tioned over the shorter ligaments. providing stability under the forefoot recognized problem disrupting normal biomechanics in the midfoot is gastrocnemius contracture or equinus deformity, a disorder that can occur asa component of triceps surae con- tracture, Manifestations of this problem include toe walking ot gait characterized by early heel-off among children or among persons with tight ligaments. Minor dysfunction can result in metatarsalgia that is aggravated by recruitment of the long toe extensors to assist the anterior tibialis in coun- teracting the force of atight Achilles tendon, Recruitment of the extensor tendon produces a gradual clawing deformity and further exposes the metatarsal heads A problem common among elderly persons and those with ligamentous laxity is gradual breakdown of the foot through the medial column at the talonavicular joint with possible naviculocuneiform or tarsometatarsal joint involvement, Such a breakdown occurs gradually, manifested first as lat- «ral and then as dorsolateral peritalar subluxation perceived by patients us arch strain ora progressive flatfoot deformity. The same condition is sometimes called a pathologic planovalgus deformity: Symptoms commonly include aching and fatigue and a slight increase in the length and possibly the \width of the foot. Secondary deformities can include forefoot jon of the frst metatarsal and hallu val patholo flatfoot is completely different supination or elev sus, The result ‘The main difference between the two types of fatfoot is that a foot with lateral peritalar subluxation drifts laterally beneath and in front of the talus to compensate for a gastroc- rnemius equinus or a triceps surae equinus deformity. As lat- ‘eral deviation increases, heel valgus and forefoot supination ‘become more prominent, the foot becomes weaker. and more symptoms occur. Further lateral deviation blocks the sinus tarsi and pushes the anterior beak of the calcaneus back into the anterolateral shoulder of the talus, frequently causing pain in the sinus tarsi. Treatment with orthoses, such as firm arch supports, usually is unsuccessful because the equinus deformity pushes the head of the talus or the talonavicular joint against the orthosis, producing localized pressure and pain, Reports by patients that an arch support causes pain in the arch usually indicates the presence of a compensatory deformity tor hindfoot equinus, Diagnosis of gastrocnemius contracture is made through clinical observation of the patient standing and a careful ex- amination of the gastrocnemius and soleus muscles. With the patient seated, the examiner passively manipulates the foot and ankle, first with the knee bent and then with the knee straight. During the examination the hindfoot, midfoot. and forefoot are positioned into neutral alignment by the exam- net. This is accomplished by means of zrasping the hindfoct,2 Medial Lateral weight Figure 1.3. tlustation depicts norma alignment in the fot. on the plantar surface ofthe foo: he tber ofthe hee. the frst metatarsal head, ing going through the tibia nt the tal dome falls within this tripod. Bs In lateral pertalar vc gantocnemivs equinus deformity the weight-bearing tipod has drifted laterally. This yes the deltoid igament, The calcaneocuboid joint and the center of weight beari subluxation with ehror causes lateral compression and medial tension and stretc Acute Trauma and Fracture Surgery Talonaviesar, joint de Vertical weight vearng Shortened alo lateral eight bearing is concentrated on three points and the third metatarsal head. The lateral ankle joint are eventually compressed and shortened. ral aspect of the heel, and holding it firmly in a neutral po- sition. The midfoot is aligned by means of internal rotation of the tarsal navicular bone and locking it into an anatomic position in front of the head of the talus. The forefoot is then ‘manipulated into plantar flexion or pronation on the hind= foot. and the entire medial ray is held immobile. The position of the foot is now similar to the locked position of a normal foot during late stance, when external tibial rotation is trans~ lated through the subtalar joint and the forefoot is supinated (Fig. 1-4), With the patient completely relaxed. the examiner ma- nipulates the foot into dorsiflexion. This manipulation is al ways done with the knee both extended and flexed. In the presence of gastrocnemius equinus. the ankle can be dorsi- ‘leved trom § degrees to 35 degrees with the knee flexed. ‘out dorsiflexion even to &t neutral position will be impossi .ge straight, The amount of dorsiflesion pos: sible with the knee bent is related to the range of motion al- lowed by the soleus or the range of motion possible in the tibiotalar joint. Markedly restricted ankle dorsiflexion war- rants radiologie evaluation for the presence of bony abnor- malities or restrictive conditions within the ankle. Surgical correction is indicated when gastrocnemius equinus in the ankle is 5 degrees or more. The results of the examination differ in the two knee positions because the gastrocnemius is a two-joint muscle, and the upper heads of the gastroc- nemius tighten when the knee is extended. A standing pos- ture produces hyperpronation in the hindfoot and the mid- foot and compensatory passive supination in the forefoot Use of a hee lift eliminates the pronation force and reduces the compensatory deformity. The same result can be achieved surgically with a gastrocnemius slide or a heel cord lengthening procedure, ‘Treatment of symptomatic flatfoot (also known as jiyper-a Functional Anatomy les iate this problem, normal activities that apply intermittent .el cord would spontaneous! ‘Night casting in a neutral position ally dorsifle the foot with the knee straight. The ankle is shown in spproxim Bs The examiner passively dorsiflexes the foot with the patient's Knee extended but does not stabilize the rection with an open Strayer-type is helpful, but surgical procedure or percutaneous lengthening of the distal heel cord usually is needed for permanent correction The amount of tension in the gastrocnemius must be as essed when metatarsalgia occurs concurrently with exten sor clawing of the lesser toes or clawing of the great toe and the lesser toes. Forefoot symptoms and 4} ss can be corrected by m excessive tightne foratight heel cord. A: The patient force. y 15 degrees of dorsiflexion. column. The ankle i capable of 10 degrees of dorsiflexion in this positon. C: The patient flexes the knee 10 90 de: ‘examiner holds the medial column in sight supi with the fingers und thumb of the right hand over the head of the talus. The medial aspects of the ion. The examiner holds the patients heel in a forefoot and midfoot are held with te lft hand. The tarsal navicular bone is brought tothe front ofthe talar head 1d hel firmly in place. With the foot relaxed, the examiner manipulates the foot into maximum dorsiflexion with ine thurnb of the lft hand, The ankle is in es of dorsiflewon, Dt The same maneuvers are used to stabi the fo08 with the patient's Knee extended. The «incapable of dorsiflexion, These manipulations le degrees of sastroesoleus rig he results achieved with the kne26 penn) ree ius lengthening, extensor tendon transfers to the midtoot intrinsicplasty. and halancing of the metatarsal head. The wal of treatment isto correet the primary cause of dysfunc tion and not merely to address the symptoms, Secondary d Tormities always must be accurately identified and managed to restore normal foot function, When substantial compen- story deformities have developed in the midfoot and fore- foot before hindfoot equinus can be corrected. they are cor- rected at the same operation, The procedures used to correct, secondary deformities might include augmentation of the posterior tibial tendon, repositioning and fusion of the nae viculocuneiform or first tarsometatarsal joints. and lengthen- ing of the lateral column, In all cases. mobility in the essen- tial joints, that is, the talonavicular and subtalar joints. should be preserved unless these joints are markedly arthritic, and painful The Hindfoot ‘The hindfoot consists of only two bones and one muscle at- tachment. but iis the site of three essential joints (the ankle, subtalar, and talonavicular) and a group of complex liga- ‘ments. Motion in the essential joints always must be pre- served. The joints must function without pain or abnormal deterioration, and they must accommodate normal gait me chanics. Motion is initiated by muscle activity or a sponta- neous reaction toa change in position of adjacent bones. Itis limited to a functional range by intraarticular and extraartic- ular ligaments, ‘As the foot evolved from an anthropoid extremity adapted for grasping and mobility to its present form, which is adapted for bipedal gait and stability, function in some joints became nonessential. For example. the apparent function of the medial arch isto protect the neurovascular and tendinous structures entering the foot from the medial aspect from be- ing crushed during standing. To do ths. the arch must be sta- ble and it must immobilize several joints in the medial col- umn. The flat joints in the medial column are held in place by a complex of short. raut intraarticular and extraarticular ligaments. In a normal foot. motion in these joints is limited toa slight gliding movement against one another. Figure 1.5. Acute Trauma and Fracture Surgery ‘The nonessential joint of the hindfoot is the calea- reocuboid joint, which functions us an intermediate joint with regard to anatomy and function, Because the calca- rneocuboid is a flat joint. its motion is limited by short cir- ‘cumferential ligaments. a dorsal osseous overhang of the an- terior calcaneus. and the plantar medial tubercle of the cuboid. which extends posteriorly into a groove in the ante- Fior calcaneus. The cuboid has a limited range of motion and ‘can move in only a plantar and medial direction from a neu- tral position in front of the calcaneus. As in nonessential joints, lack of motion in thé intermediate joints does not sreatly affect foot function. The triceps surae isthe only muscle that attaches directly into the hindfoot. Acting through the calcaneus in a trans- verse axis of rotation, this muscle exerts a strong plantar flexion force on the hindfoot. Another structure that controls hindfoot function isthe ankle mortise on the lateral wall of the talus. Dynamic motion in the ankle mortise is produced bby medial rotation of the talus by the tibia between heel strike and midstance. Once the foot is planted firmly on the ‘ground, the talus rotates internally and flexes in relation to the calcaneus and the navicular bones through the subtalar and talonavicular joints, respectively. The otherwise firm ‘medial ach is flattened inthis position, and itallows the foot to absorb the impact of body weight striking the ground dur- ing this part of the gait cycle. Rotation of the foot in elation to the talus is restricted by the attachments of the calcaneonavicular and talonavicular ligaments and the posterior tibial tendon in the midfoot. Af- ter midstance, the tibia rotates externally through the con- tralateral leg and pelvis during swing. When the foot is flat on the ground, the talus rotates externally in relation to the rest of the foot. This motion causes the subtalar and talona- ‘vicular joints to raise and stiffen the arch and to lengthen the lever arm of the foot to the metatarsal heads. With the artic~ ulation between the hindfoot-midfoot junction rigid, con- ‘action of the triceps surae can create a pushotf force that is ‘carried all the way to the metatarsal heads and the toes. The strong force of the posterior tibial tendon locks the midfoot medially in relation to the head of the talus and helps t0 stiffen the foot. As the midfoot locks, the tarsal navicular and > IMustration depicts normal and abnormal alignments between the talus and the frst metatarsal ‘Comparative anteroposterior weight-bearing views of a normal foot (A) and a foot with a hallux valgus deformity show a break in the talar-first metatarsal line and displacement ofthe talar head on the navicular bone (B). The foot with deformity has rotated laterally and dorsally around the talus through the talonavicular and subtalar joins. Comparative weight-bearing lateral views show a normal foot (C) and a foot with a tight heel cord and dorsolat- eral pertalar subluxation from the medial aspect (D). The break inthe talarfirst metatarsal axis is most prominent atthe naviculocuneiform joint butt also can be seen atthe cuneiform-first metatarsal joimts. The planta ligaments are stretched. and dorsal exostosis of the First cuneiform and the head of the talus is present. Dorsal translation of the base of the first metatarsal on the face of the frst cuneiform is present. Weight-bearing lateral views of a nor- ‘mal foot (E) and a foot with deformity show a sag in the talar-first cuneiform line and the presence of compen satory equinus oF dorsolateral pentalar subluxation deformity resulting from gastrocnemius contracture (F).Patho- loge eh ‘lenson the oor of the sinus include plantar tlexion and apparent shortening of the head of the talus, i, The calcaneus has rotated laterally under the talus until the anterior beak of the talus, Further rotation is prevented this nony eck losure ofthe sinus tarsi and28 hawt the cuneiform bones assume their positions at the keystone of the arch. The arch is stabilized further by the long per- neal tendon, whieh plantarilexes the first metatarsal or medial forefoot In addition to cushioning gait und stabilizing pushott, the subtalar joint adapts the toot to uneven surfaces, The ankle is primarily 3 uniplanar sagittal) hinge joint and must maintain hormal motion to push off during gait and adapt the foot to slanted surtaces in a single plane, that is. a slope eunning up ‘or down in the Fine of progression, Because it responds to un= ‘even surfaces only with flexion and extension, the ankle by itself cannot aljust to surtaces ited in the transverse plane. ‘The subtalar joint conforms the foot to irregularities and pro~ tects the ankle ligaments and articular surfaces in the hindfoor trom harmful stresses, Working together. the ankle and subtalar joint adapt the foot to uneven surfaces and maintain a stable bipedal stance and gait even with only one foot on the ground. This unique evolutionary development in the foot has freed our hands for using tools and. in turn, allowed our brains to invent better and more imaginative uses for those tools. Coming from an orthopaedic foot surgeon, such musings may be considered biased. yet they are supported by anthropologic evidence. Traits Associated with Foot Dysfunction “The most important concept to take away from the study of functional anatomy of the foot is that two seemingly atavis- tic traits are predominant in dysfunctional feet. They are gas- trocnemius contracture and frst metatarsal dysfunction due to fitst cuneiform-first metatarsal joint instability. These traits occur so frequently that most examiners doubt their rel- evance to many of the problems they see and consider them to be pertinent only when a severe pathologie condition is present. “These traits have been implicated in the occurrence of symptomatic flatfoot (including posterior tibial tendon dys- function. insufficiency. and rupture), metatarsalgia, and. less commoniy in plantar fasciitis and hallux valgus. Gastrocne- ‘ius contracture has long been recognized in both the podi- atric and orthopaedic literature to be detrimental to normal {oot function. The concept certainly does not originate with ime. Lapidus strongly suspected that forefoot abnormalities ‘were caused in large part by hypermobility or instability in the First metatarsal but was frustrated in his attempts to fuse the joint in a corected positon by lack of adequate internal fixation ‘Some patients refuse to accept the concept of atavism on religious grounds, These individuals should be encouraged to recognize the problem when it exists and possibly to call it something else. When | explain to patents the pathophys- iologie mechanisms of « tight gastrocnemius. I suggest they 40 home and examine their dog or cat. Once they locate the Siimal’s heel and ankle. they can see that both structures are Acute Trauma and Fracture Surgery well off the ground when the animal is standing with the knee straight. Conversely, the ankle cannot be dorsiflexed and the heel brought to the ground unless the knee is bent. This phenomenon clearly isa consequence ofthe presence of 4a short, wwo-joint muscle or band, In other animals. this mus- tle is also called the gastrocnemius. Hypermobility in the First ray is easier 10 identify because almost everyone has seen an anthropoid foot with a mobile opposable fist ray at the 200 or in a movie. Foot surgeons must learn to identify these traits both in a physical examination and from radiographs. Gustrocnemius ‘contracture can be identified by means of testing dorsflex- jon withthe knee both bent and straight and withthe medial column stabilized in an anatomically neutral or slightly supinated position. Testing in these positions eliminates compensatory pronation or dorsolateral peritalar subluxation that patients might have adopted. Radiologic studies should include at least AP and lateral projections with the patient standing and the knee straight. This posture exaggerates dor- solateral pertalar subluxation, which can be aggravated or caused by the presence of a short gastrocnemius. On radio- ‘graphs, itis seen as a break in the talar-first metatarsal line in both projections (Fig. 1.5). Hypermobility in the first metatarsal also can be diag- nosed through physical examination and radiologic studies. To identify hypermobility during a physical examination. the examiner stabilizes the lesser metatarsal heads in maxi ‘mum dorsiflexion with the thumb of one hand and manipu- lates the first metatarsal head into maximum dorsiflexion with the thumb of the opposite hand. The patient's foot must bee relaxed during this manipulation, The amount of overall mobility is less important than elevation of the first metatarsal head. Elevation greater than $ to 8 mm dorsal to the second and third metatarsals constitutes hypermobility. ‘Other findings in the physical examination also are impor- tant to confirm first metatarsal hypermobility. These include callus formation that is heavier under the second and third than under the first, the presence of a plantar medial ridge of callus under the fist interphalangeal joint, and evidence of a ‘bunion. The lesser metatarsal heads may be surrounded by boggy synovitis, indicating chronic overload. The most im- portant finding is instability, subluxation, or even dislocation of the second or the second and third metatarsophalangeal joints. In the absence of inflammatory arthritis, chronic syn~ ovitis and capsular destruction arise from first metatarsal dysfunction and excessive weight bearing by the second and third metatarsals, It is also possible forthe first metatarsal to be relatively short in comparison with the others. a condition called Morton’s foot. Weight-bearing radiographs may show first metatarsal varus, second metatarsal hypertrophy. or second and third metatarsal hypertrophy. They also may reveal the presence of Freiberg's infraction, second or third metatarsophalangeal subluxation or dislocation, and second or second and third tarsometatarsal arthrosis (Fig. 1.6). Other findings may in- clude osteoporosis in the first metatarsal, hallux valgus,5? TABLE 1.3. Major Extrinsic Musc ‘Acute Trauma and Fracture Surgery ~ les and Tendons of the Foot and Ankle Major extrinsi Anatomic structure muscles and tendons Function Supertoial posterior eniies tendon The Achiles tendon faciitates ankle plantar ‘compartment flexion, Posterior tibial tendon During weight bearing the posterior tial ‘tendon stabilizes the medial column. In the Deep posterior companment _Flexar hallucis longus Flexor digitorum communis (4 slips) Peroneus longus Lateral compartment Peroneus brevis Peroneus tertius Anterior tibial tendon Anterior compartment Extensor hallucis longus Extensor digitorum communis (4 sips) TP. interphalangeal: MTP, metatarsophalangeal. arthrosis in the frst metatarsophalangeal joint. or hallux tigidus, Elevation ora Lower level of inclination of the first tretatarsal than of the second and third are Frequently seen in the lateral radiographic view. Gastrocnemius contracture and first metatarsal hypermo- bility are traits that frequently occur together. bunion is fone of the most common manifestations of this syndrome Management of a bunion by means of the dozens of tech- niques described in the literature is simplistic because in fhany instances the bunion is only one visible symptom of {reatly more complex dysfunction, Examinations of feet that exhibit symptoms or are dysfunctional should be performed swith one primary question uppermost in the examiner's l2bsence of weight bearing, it mediaizes the midfoot bones and inverts the hindfoot ‘The flexor hallucis longus flexes the first IP joint and acts in conjunction with the intrinsic muscles to elevate the first metatarsal head ‘The flexor digitorum communis flexes the lesser toe IP joint and acts in conjunction ‘withthe intrinsic musciés to provide Secondary elevation of the lesser ‘metatarsal heads and to distribute weight bearing among them. ‘The peroneus longus plantar flexes the first ‘metatarsal and pronates the forefoot. it iso inereases the arch of the medial column. ‘The peroneus brevis everts th abducts the forefoot. ‘The peroneus tertius dorsifiexes and everts the foot. ‘The anterior tibial tendon elevates the first ‘metatarsal and supinates the forefoot Itis the antagonist of the peroneus longus and triceps surae. “The extensor hallucis longus dorsifiexes the first IP joint and provides secondary first metatarsal plantar flexion by means of the windlass mechanism. “The extensor digitorum communis extends the lesser MTP joints and provides secondary ankle dorsiflexion. 12 hindtoot and mind: “What is the cause of this problem?” It may well be that it stems from an atavistc trait References physiology and fetional Morton DJ. The ftuman foo: its evoltion. versity Pres, 1985. orders Morningside Heights. NY: Columbia Uni tide PW. Operative correction ofthe metaarsus varus primus in fallux valgus, Sure Gynecol Obstet 1934:58:183-191 tan UT The int ofthe enle Baliore: Williams & Witkin 1905 Taman VE Ralston HY. Todd F Haman walking, Baltimore: Wiliams & Wilkins, 981 Surafian SK. Anatomy ofthe oot and ankle: descriptive “Favronal Philadephia: JB Lippineot. (983, poraphic