Chapter 25: Trauma

Medical Management and Assessment of the Polytrauma Patient Assessment of Lower Extremity Injury General Evaluation and Treatment of Fractures Calcaneal Fractures Talar Fractures Osteochondral Fractures Navicular Fractures Cuboid Fractures Cuneiform Fractures Fifth Metatarsal Base Fractures Metatarsal Fractures (1st, 2nd, 3rd & 4th) Tarsometatarsal Joint Dislocations/Fractures Subtalar Joint Dislocations Ankle Fractures Ankle Inversion Sprain Deltoid Ligament Ruptures Compartment Syndrome Open Fracture Classification System and Treatment Soft Tissue Injuries Crush, Gunshot, and Lawnmower Injuries Puncture Wounds Epiphyseal Plate Injuries (also see chapter 19,

Digital Fractures and Dislocations 1st MPTJ Trauma Nail Bed Trauma Toe Tip Injuries With Tissue Loss Dog and Cat Bites

TRAUMA Medical Management and General Assessment of the Trauma Patient
1. First Priorities: a. Evaluate and establish an appropriate airway and ventilate with 100% oxygen (intubate if ventilation is inadequate, but stabilize cervical spine with Philadelphia collar) b. Control external hemorrhage c. Inspect patient for skin color, alertness, chest wall motion, and extremity motion d. Auscultate the chest for breath sounds and establish adequate ventilation (if suspect pneumothorax with respiratory distress, insert chest tube without waiting for x-ray confirmation) e. Obtain vital signs NOTE* Carotid pulse is palpable at systolic BP of 60 mm Hg, femoral pulse at 70 mm Hg, and radial pulse at 50 mm Hg

f. If pulselessness/hypotensive from blunt trauma to chest or a penetrating wound of precordium with distended neck veins not relieved by thoracostomy tube, open chest for effective CPR g. Establish IV lines and begin infusion (if patient is hypotensive use femoral lines via cutdown in conjunction with upper extremity infusion). Use crystalloid, colloid and/or blood as indicated (lactated Ringer's is preferred because it prevents metabolic acidosis) NOTE* In general, blood transfusions should be instituted when crystalloid infusion exceeds 50 ml/kg

NOTE* If systolic BP is less than 100 mm Hg, place IV in both antecubital spaces, and if inaccessible do greater saphenous cutdown h. If patient still hypotensive insert arterial line to monitor BP and blood gases i. Initiate EKG monitoring j. Assess neurologic status by Glasgow coma scale i. Check pupillary response, extremity posturing, and response to commands ii. Evaluate motor function of all extremities and trunk iii. If sensory and/or motor deficit, establish spinal cord level of functional changes k. Obtain admission blood work (CBC and coagulation profile, arterial blood gases, urinalysis, and venous blood chemistries) 2. Second priorities: a. Obtain a H&P if possible

b. Secondary examination of the head, chest, abdomen, pelvis, and extremities with attention paid to life threatening injuries c. Obtain appropriate x-rays (cervical, chest, etc.) d. Place a Foley catheter and check for occult blood in the urine e. Place a NG tube and check for occult blood in the GI tract f. Splint extremity fractures g. Complete neurologic examination h. Tetanus prophylaxis i. Culture and sensitivity of open wounds j. No antibiosis unless specific indication is apparent k. Perform emergency surgery if required 3. Third priorities: a. Systematic evaluation of the body b. Specialty radiology (CT, angiograms) c. Specialty consultations d. Invasive monitoring (Swan-Ganz) e. Urgent Surgery

Assessment of Lower Extremity Injury
1. Examination: a. Rapid neurovascular assessment NOTE* Lower extremity injuries are of low initial priority unless there is frank bleeding. With an arterial injury, there is a pulsatile flow or spurt of bright red blood. if present exert manual pressure initially, surgical repair later b. Quantity and quality of pulses c. Observe motor function d. Inspect for lacerations, swelling, deformities e. Joints palpated NOTE* Signs of ischemia are pain, pallor, paresthesias, paralysis, pulselessness. You have 6 hours to reverse before permanent pathological changes occur 2.

Traumatic limb or digital amputation salvage: a. The avulsed part should be placed in sterile saline soaked gauze, sealed in a plastic bag, and immersed in ice water b. The avulsed part that has been properly cooled may last up to 24 hours c. The avulsed part that is not cooled within about the first 8 hours has a poor chance of being replanted

General Evaluation and Treatment of Fractures
1. Determine type of fracture: a. Classification of fractures: i. Transverse ii. Oblique iii. Spiral

Excision of fracture fragments e. Rotation iv. How is the blood supply to the fractured segment? vi. Step 3. laceration of the kidney-renal damage.Distract the fragments iii. Immobilization. There are a number of associated injuries when dealing with a calcaneal fracture including: compression fracture of the lumbar vertebrae. Elevation b. Is the area subject to movement? iv. Intraarticular or extraarticular d. Anatomical considerations: a. Step 1. and compartment syndrome 1.Reverse the mechanism of injury c. fractures of the lower extremity. Stable or unstable: i. Ice. Displacement 2. Length and location ii. How much bone to bone contact is there? ii. Description of a fracture based upon the 4 basic relationships (described by the mnemonic LARD): i. Are the fragments well aligned? iii. The mechanisms of closed reduction are: i. The largest tarsal bone that has a thin cortical shell enclosing cancellous . Rest. Cortical or cancellous bone involvement NOTE* Characteristics of cortical and cancellous bone Cortical Osteogenic properties poor Fractures surfaces small Soft tissue support poor (few) Vascularization poor Inherent stability poor Cancellous good large good good good e. Open reduction (with or without internal fixation) d.Increase the deformity ii. What kind of bone is involved in the fracture? c. Treatment of fractures: After determining the location and evaluating the patient's physiological status. Closed reduction (with or without internal fixation). a treatment regimen is tailored to the patient's needs: a. Compression. Open or closed d.iv. Comminuted b. How extensive is the soft tissue involvement? v. Angulation iii. Amputation Calcaneal Fractures A disabling injury of the foot. Step 2.

and the inferior extensor retinaculum. The calcaneus articulates with the talus through 3 facets. female patients predominate. The middle and anterior facet have a common joint cavity with the TN joint and are separated from the larger posterior facet by the sulcus calcaneus.bone that contains traction trabeculae radiating from the inferior cortex and pressure lamellae converging to support the posterior and anterior facets. Type 3: Oblique body fracture not involving the STJ vii. Tomography c. Plain film x-rays i. CT scanning (The Gold Standard) 3. Type 1a: Fracture of the tuberosity ii. Type 1b: Fracture of the sustentaculum tali iii. replacing Rowe 4 8 5) a. Classification: Due to the fact that two types of fractures exist (intraarticular and extra-articular) the classification that is best used is a combination of the Rowe (inclusive for extra-articular) and Essex-Lopresti (inclusive for intra-articular. Boehler's tuber joint angle overlies the posterior articular facet and is a measurement of the sagittal plane between the anterior and posterior aspect of the calcaneus (normal 20-400) f. mostly related to wearing high heeled shoes) iv. Type 2b: Avulsion fracture involving the tendo Achilles insertion vi. the EDB. Rowe: i. Type 5: Joint depression fracture with comminution . Gissane's critical angle is the position that abuts with the lateral process of the talus and which under compression force acts as a wedge creating the primary fracture line in the calcaneus 2. Type 4: Body fracture involving the STJ viii. Type 1c: Fracture of the anterior process (most common. Radiological Examination a. Isherwood views:  Oblique lateral (anterior process and calcaneocuboid)  Medial oblique axial (medial and posterior facet)  Lateral oblique axial (posterior facet) v. Anthensen's view (demonstrates medial and posterior facets of the STJ) iv. A-P NOTE* Evaluating integrity of the bone plus Boehler's angle and the Critical view angle of Gissane is essential in the diagnosis ii. Lateral view iii. the largest being the posterior c. b. e. The lateral end of the tarsal canal gives attachment to the bifurcate ligament. Type 2a: Beak fracture v. Broden's projections  Broden 1 (shows the posterior facet from anterior)  Broden 2 (shows the sinus tarsi to posterior) b. d.

Mechanism of injuries: a. Type 2: two part posterior facet fracture (a) Fracture through the lateral column (b) Fracture through the central column (c) Fracture through the medial column iii. Avulsion fx iii. Falls from a height (intra-articular fractures) . Anterior process fx ii. Sustentacular fx b. Type 3: three part posterior facet fracture with central depression (ab) Fracture through lateral and central columns (the bone between FX a and b is depressed) (ac) Fracture through lateral and medial columns (the bone between FX a and c is depressed (bc) Fracture through the central and medial columns (the bone between FX b and c is depressed) iv. Fractures involving the calcaneal-cuboid joint:  Parrot-nose type  Various iii. Direct impaction (extra-articular fractures) i. Type 4: Four part posterior facet fracture 4. Fractures involving the STJ:  Without displacement  Tongue-type with displacement  Centro-lateral depression of the joint  Sustentaculum tali fracture alone  Comminuted NOTE* The primary fracture line is vertical from the vertex of the critical angle of Gissane to the plantar aspect. Fractures not involving the STJ: Tuberosity fractures  Beak type  Avulsion medial border -Vertical  Horizontal ii. The secondary fracture line is determined by the direction of the force c. This is the first system to have a prognostic value i. Torque injuries (extra-articular fractures) i. Sanders: A new classification that utilizes CT scanning rather than plain radiographs for its identification.b. Essex-Lopresti: i. Beak fx c. Type 1: nondisplaced ii. Tuberosity fx ii.

Pes planus antalgic gait iii. Pain with ROM of ankle and STJ e. anterior to the lateral malleolus ii. Ankle joint ROM WNL f.d. Flattened arch vi. Inability to bear weight ii. and MTJ within normal limits d. Fracture of sustentaculum tali i. Severe bleeding under fascia iii. Fracture of the body no STJ involvement i. Decreased plantarflexion (Hoffa's sign) vii. Beak fractures . Small fragment fractures  Soft cast NWB for 2-4 weeks (early mobilization important) ii. Inversion and adduction increase pain NOTE* Must R/O 5th metatarsal base fractures b. Concussive force from below (intra-articular fractures) 5. Widened heel viii.well defined 3-4 cm. ecchymosis. Rapid edema and severe pain and inability to bear weight ii. edema. Discoloration of the heel extending to the calf iv. STJ ROM decreased and painful iv. Clinical Diagnosis of Calcaneal Fractures: a. Heel thickens. STJ. Edema/ecchymosis iii. Tongue depression fractures i. Beak and avulsion fractures: i. Fractures of the medial and lateral process: i. and ecchymosis ii. Pain inferior to medial malleolus on dorsiflexion (FHL) iii. Blister formation v. Anterior process fractures: i. Generalized pain around the heel iv. bullous lesions (Mondor's sign) c. R/O compression fracture of lumbar vertebrae and ankle (10% occurrence) 6. Large displacement fragment  RIF or excision (it is recommended to wait 1 year before excision) b. Edema. Swelling. Anterior process fractures: i. Weakness of plantarflexion iv. Pain and edema on the medial aspect of the foot 1 inch below the medial malleolus ii. "Pop" sound heard/felt on the heel with sudden pain ii. ROM of ankle. Treatment: a. Beak or avulsion fractures: i.

reconstruction plates. Compression dressing/ice/elevation ii. and lateral impingement syndromes).5 mm.5 mm. Neutralize the entire calcaneus with 3. For displaced fragment closed reduction followed by BK NWB cast for 6 weeks  d. The medial approach is used when needed for more accurate reduction and rigid stabilization. For non displaced use compression dressing/ice/elevation with ROM exercises immediately (NWB 4-6 weeks) ii. After edema subsides. ROM excercises immediately for FHL iii. closed reduction with BK NWB cast 6-8 weeks (Steinmann pin can be used with proximal displacement) e. cortical or 4. anterior ankle arthritis developed. Timing is important to give a satisfactory result. Avulsion fractures  ORIF followed by screw fixation followed by BK NWB cast in plantarflexion for 4 weeks followed by a neutral position BK cast for 2 weeks c. Because of this. For nondisplaced treat with compression dressing/ice/elevation NWB. Fractures of the medial and lateral process: i. Fracture of the sustentaculum tali: i. new techniques have been advocated. However. If the talus was left impacted into the posterior facet region. or cervical plates (plates are recommended for neutralizing the interfragmental screw repair and for holding the lateral wall . Either 3. follow with well molded BK cast for 4 weeks iii.BK cast 4-6 weeks (weight bearing if fragment not displaced)  If fragment displaced closed reduction followed by BK NWB cast for 6 weeks in plantarflexion with gradual weightbearing  RIF (screw) if closed reduction unsuccessful followed by BK NWB cast ii. Firm shoe with orthoses v. down to the subperiosteal layer. A wide lateral flap is made incorporating the peroneal tendons and sural nerve. flattened 1/3 tubular plates (possible in combination). Fracture of the body not involving the STJ: i. Open Reduction Technique: The lateral approach is used most for the primary incision. but immediate fixation can also be done if the fracture is open or is associated with a compartment syndrome Several technical options are available with regard to hardware: a. Some advocate waiting 4-7 days to allow the swelling to resolve. cancellous screws can be used to fix the reduced posterior facet to the sustentacular fragment b. significant malalignment in varus or valgus. If displaced.0 mm. If displaced closed reduction followed by BK cast 4 weeks NWB followed by weight-bearing 2 weeks NOTE* Treatment for significant calcaneal fractures has traditionally been conservative (either closed reduction or posterior percutaneous pin fixation). calcaneal fractures treated by these methods resulted in a marked disability that gradually resolved to a tolerable level but with many sequelae (widening of the heel. BK cast with progressive weightbearing iv. or when CT scan demonstrates that most of the pathology lies medial in the fracture.

A plate stabilizing the lateral wall (the plate is the key in preventing the posterior heel from drifting into varus) c. Open reduction (extensive) c. and lock in the medial cortices before the lateral-to-medial lag screws are inserted 7. visual alignment of the fracture through Gissane's angle. The patient is taken to the OR and using fluroscopic control. some feel that a bone graft is necessary under the posterior facet after it has been elevated from the body of the calcaneus b. If the articular surface and posterior tuberosity are noted to fall into proper alignment the pin is advanced into the anterior calcaneus to fixate the fracture. A bone graft would not be necessary if adequate lateral to medial wall reduction is performed. then reduction must be considered anatomic . A second pin may be driven parallel to the first for added fixation. Displaced intra-articular calcaneal fractures require open reduction in order to restore joint congruency b. and radiographic absence of an intra-articular step off at the posterior facet with reduction of the medial wall on the axial view. Summary of correction: If there is visual congruency of the subtalar joint. A transverse K-wire is inserted through the calcaneus to attach a Kirschner traction device for manipulation (traction reduces the medial wall) d. A BK cast is applied c. A transverse K-wire or Schanz screw is inserted into the posterior body and helps reduce the Medial wall indirectly to pull the heel out of varus. The Essex-Lopresti maneuver can be used in elderly patients with intraarticular tongue-type fractures who cannot tolerate surgery NOTE* The Essex-Lopresti maneuver is a technique of reduction. This is accomplished by pushing the protruding portion of the pin downward toward the plantar aspect of the heel. a Steinmann pin is driven into the posterior tuberosity from the posterior aspect of the heel.f. The pin is then used as a lever to elevate the impacted and depressed joint surface and tongue portion. Further considerations of treatment of intra-articular fractures: a. Tongue and joint depression fractures: i. However. Closed reduction ii.

Complications of Calcaneal Fractures: a. Rigid pes planus j. Posterior facet: Indication for ORIF is with more than a 3 mm step off involving the posterior facet or if there is an angulation of the tuberosity fragment greater than 10 0 b. Sural or posterior nerve entrapment h. Medial approach: The main advantage of this approach is in the direct visualization of the reduction of the posteriolateral fragment and the superiomedial fragment and sparing the peroneals and sural nerve i. therefore should be reduced d. medial wall (determines height). Calcaneal cuboid joint: Involvement can be treated with closed reduction 8. MTJ. Surgical incisions: a. Stephenson vertical incision iii. Osteoarthritis of the STJ. Oilier incision iii. Lateral wall pathology: Lateral wall disruption can cause sural nerve irritation and peroneal tendon dysfunction. Infection NOTE* In cases of severe comminution. Bony prominence f. lateral wall blow out (determines width) and calcanel cuboid joint a. Heel pain b. and should be treated with ORIF c. Flexor tenosynovitis g. Heel pad damage e. and can be extended proximally if a concomitant ankle NOTE* The most advantageous approach includes the use of a primary lateral incision with an ancillary medial incision if there is difficulty reducing the posteriolateral and superiomedial fragments fracture is present) 9. Medial wall pathology: 1 cm or more displacement of the medial wall is indicative of increased shortening and increased width. an excellent expansile incision which exposes the entire lateral rearfoot complex via a subperiosteal flap. Modified -Kocher incision ii. Peroneal tendonitis c. the question of primary subtalar fusion or triple arthrodesis is still debated . Zwipp medial "L" incision b.NOTE* The 4 areas to consider when evaluating the intra-articular fracture of the calcaneus are posterior facet disruption. the calcaneocuboid joint and most importantly the posterior facet (site of major pathology) i. Lateral approach: Gives expansile exposure to the lateral wall of the calcaneus. and ankle joint d. Right angle incision (consists of a vertical and horizontal arm. Reflex sympathetic dystrophy k. McRenolds horizontal incision ii. Calcaneus gait (weak plantarflexion) i.

Fractures of the body: i. The talar neck is supplied by an anastamosis of 2 vessels: i. Fractures of the neck (Hawkins' classification): All caused by some fall or accident resulting in a severe dorsiflexory force to the foot i. Compression fractures c. Non displaced ii.Talar Fractures 1. Displaced iii. The 3 main parts are the head. Chips and avulsions b. Anatomy: a. Group 2: Vertical fracture of the neck that is displaced. following injury. No muscular or tendinous attachments c. Posterior tibial (#1) ii. Group 4: The fracture of the talar neck is associated with dislocation of the body from the ankle and the subtalar joints with an additional dislocation or subluxation of the head of the talus from the T-N joint  Avascular necrosis reported in 100% of cases NOTE* Hawkins' sign is an area of translucency of subarticular or subchondral bone seen on x-ray. between the posterior and middle is a transverse groove which (with the calcaneus) forms the tarsal canal that exits laterally into the sinus tarsi 2. The neck deviates medially 15-200 and is its most vulnerable part d. the STJ is subluxed or dislocated. Artery of the tarsal canal 3. Classification: a. The FHL lies within a groove on the posterior talar tubercle held by a retinacular ligament e. Perforating peroneal (#3) b. Extraosseous blood supply comes from: i. Anterior tibial (#2) iii. Group 3: A vertical fracture of the neck that must be displaced and the body of the talus must be dislocated from both the ankle and subtalar joints  All three sources of blood supply are disrupted (91 % chance of avascular necrosis) iv. Artery of the tarsal sinus ii. 2nd largest tarsal bone with more than 1 /2 the surface being cartilage b. Inferiorly 3 facets are present. body and neck. Comminuted d. Blood supply: a. which indicates healing is occurring . and the ankle joint is WNL  Two main sources of blood supply are interrupted (a 42% chance of avascular necrosis has been reported)  Prognosis is related to the development of avascular necrosis iii. Group 1: Vertical fracture of the neck that is undisplaced  One of the three sources of the blood supply is disrupted (a 13% chance of avascular necrosis has been reported) ii.

Dislocations: i. Group 4:  As per Group 3 NOTE* If the talus must be removed. Talar neck: i. a Blair procedure is recommended NOTE* Arthrodesis procedures have been stated to give better results as a secondary procedure than a talectomy alone NOTE* Hawkins grades 3 and 4 fractures were thought to be unsalvagable but with modem ORIF techniques there are improved chances of restoring normal function after injury. Group 2:  Closed reduction with BK/NWB cast until evidence of union  Early ORIF when and if closed reduction fails or the original reduction is unstable (prognosis related to the development of avascular necrosis) iii. Posterior dislocations iii. Group 3:  ORIF with accurate anatomical reduction must be achieved followed by BK/NWB cast for 3-4 months (prognosis is poor)  iv. Treatment: a. followed by NWB with no cast for an additional 2-5 months with ROM ankle excercises (prognosis is excellent)  ii. .NOTE* Early anatomical reduction in displaced fractures yields the most favorable long term results e. Total dislocation 4. Lateral dislocations iv. Group 1:  BK/NWB cast for 6-12 weeks. Anterior dislocations ii. Fractures of the talar dome (Berndt and Harty): see section Osteochondral fractures f. Medial dislocations v.

and to encourage revascularization c. An additional blood supply courses into the undersurface through the talocalcaneal ligament b. transverse Cincinnati incision or a posterolateral vertical incision work well) . The operative incision to the talus must not inflict any additional harm to the arteries bringing blood to the body and the neck the most critical blood supply coming from the posterior tibial in the deltoid: ligament attachment.a. The talus must be reduced as quickly as possible to protect any remaining blood supply by untwisting and reducing tension in the deltoid ligament. An atraumatic operative approach is needed that allows adequate visualization for anatomic reduction (Oilier lateral incision.

Lateral lesions: Inversion and dorsiflexion b. head directed medially. Painful with associated collateral ligament damage  Lateral dome lesions have pain over the lateral collateral ligaments  Medial dome lesions have pain over the deltoid ii. The assistant inverts and plantarflexes the foot. Diagnosis: a. Manipulation:  Usually not successful but should be attempted ii. Usually no symptoms. Lateral lesions are shallow wafer shaped and of injury: medial lesions are deep cup shaped a. Stage 1: A small area of compression of subchondral bone b. and has been diagnosed as an ankle sprain ii. Ankle ROM may be limited due to traumatic synovitis c. Lateral process: i. Skeletal traction:  Steinmann pin through calcaneus attached to traction apparatus to achieve an open space between the tibia and calcaneus. NOTE* It has been found that 44% are lateral and anterior. the pin is removed and the foot is immobilized in an anterior and posterior splint for 7 days with the knee bent to 300 and ankle at 90°. Osteochondral Fractures 1. plantarflexion and lateral rotation of the tibia on the talus 3. Stage 2: A partially detached osteochondral fragment c. Undisplaced:  BK cast partial weight bearing 4 weeks i. Total talar dislocations (out of the ankle mortise and STJ. as the surgeon presses both thumbs on the posterior aspect of the talus by inward and backward movement to rotate the talus. ROM of the ankle is WNL and painless b. Stage 4: A displaced osteochondral fragment 2. Afterward. anterior to the fibula. Avascular necrosis is inevitable. d. Medial lesions: Inversion. Stage 3 8 4: .b. This is followed by a BK cast for 6-8 weeks.  If there is an open wound treat appropriately. Stage 2: i. talus rotated on the longitudinal axis so its inferior aspect points posteriorly): i. Stage 3: A completely detached osteochondral fragment remaining in the defect. and 56% are Mechanism medial and posterior. Displaced:  Excision of bone fragment if symptomatic c. Classification (Berndt and Harty): a. Stage 1: i.

Pain is more severe ii. but the use of tomograms or CT are best 4. definable but nondisplaced fragment Displacable fragment Loose body Stage 2 Semicircular fragments Subcortical lucency Semicircular fragment Loose body Stage 2A Stage 3 Stage 4 . joint locking or crepitus. and/or instability of the collateral ligaments Note* The diagnosis can be made on x-ray (the A-P view shows the medial talar dome clearly. Surgical: For stage 3 lateral and 4. 2. Conservative: For stage 1. conservative vs.i. However. Decreased ROM of the ankle. Treatment: a. the lateral dome is obscured but can be visualized in the medial oblique). or stabilize fragment using K -wire or Herbert screw NOTE* Review of the literature reveals that surgically treated patients have better results in preventing post-traumatic arthritis. surgical treatment depends upon the size/location/stage of the fracture fragment Staging System for Osteochondral Lesions Radiographs Stage 1 Normal T2W-MRI Marrow edema (diffuse high signal intensity Low signal line surrounds fragment High-signal fluid within fragment High signal line surrounds fragment Defect talar dome Arthroscopy Normal or irregularity and softening of cartilage Articular cartilage breached. surgery to remove fragment. 3 medial lesions via NWB BK cast for 6 weeks followed by a patellar-bearing brace until the fracture heals b.


Relatively common as compared to other types ii. Treatment is with an Unna-type boot of BK partial weight-bearing cast x 4 weeks..Fracture of the tuberosity i. cuneonavicular ligaments and the cubonavicular ligament c. and this problem is often misdiagnosed as anterior tibial tendonitis 1. Isolated fractures are uncommon. The combination of a severely displaced fracture and compression fracture of the cuboid and/or calcaneus is referred to as the NUTCRACKER SYNDROME vii. The lateral surface serves the attachment for the navicular portion of the bifurcate ligament e. The mechanism of this fracture is acute eversion of the foot causing an avulsion-type fracture. The blood supply is from the dorsalis pedis and the medial plantar artery which form an arcade of 6-8 randomly arranged vessels that penetrate the navicular surface (the central 1 /3 is relatively avascular) 2. caused by increased tension placed on the tibialis posterior tendon iii.Navicular Fractures Fractures of the navicular are easily missed. These fractures are generally non-displaced because of the multiple soft tissue attachments to the tuberosity iv. It is important to differentiate this fracture from a type II accessory navicular vi. The plantar surface is so roughened and is invested by the plantar calcaneonavicular ligament (spring ligament) d. Navicular Fracture Classification by Watson-Jones a. Type I. The dorsal navicular surface is roughened and serves as an attachment for the dorsal talonavicular ligament. Stress fractures of the navicular have been seen in runners but more frequently in basketball players. The navicular tuberosity provides the major attachment site for the posterior tibial tendon f. and are important to diagnosis quickly as a delay in treatment could lead to traumatic arthrosis of Lisfranc's joint as well as the T-N joint. Anatomy: a. Best demonstrated radiographically on the AP and oblique x-ray with the foot in moderate equinus v. If a symptomatic non-union occurs it is recommended that the fragment be . If the type I fracture is severely displaced you should suspect calcaneocuboid involvement vii. and usually occur in conjunction with Lisfranc's dislocations and fractures of the rearfoot. viii. Cancellous bone which is convex distally where it articulates with the three cuneiforms and is concave proximally to accomodate the talar head b.

removed and reattachment of the tibialis posterior performed

b. Type II- Fracture of the dorsal lip

i. Most frequent fracture of the navicular and is intraarticular ii. The mechanism of injury is plantarflexion of the foot followed by either forced inversion or eversion iii. Best seen on the lateral x-ray iv. Can be confused with 2 accessory ossicles in the same area, the os supratalare and os supranaviculare v. Treatment is with a BK partially weight-bearing cast for 4-6 weeks vi. If late problems such as a painful dorsal prominence occurs, excision of

the fragment is recommended c. Type IIIA - Fracture of the body without displacement d. Type IIIB - Fracture of the body with displacement

i. A severe injury that causes disruption of the talonavicular and cuneonaviclar joints ii. Can be either displaced (type A) or nondisplaced (type B) iii. The mechanism of injury can result from either direct crush or blow, or indirect from a fall from a height with the foot in a marked plantarflexion position at the moment of impact iv. These fractures are usually intraarticular v. DP, lateral, and oblique x-rays will demonstrate the fracture vi. A differential diagnosis for a type Ill navicular fracture include a bipartite tarsal navicular and lithiasis of the navicular vii. Treatment of nondisplaced fractures is with a BK walking cast for 6-8 weeks viii. Treatment of displaced fractures is with ORIF and a BK non-weightbearing cast for 6-8 weeks e. Type IV- Stress fracture of the navicular

i. Usually an athletic injury, most commonly track and field ii. Symptoms are increased pain with activity, and decreasing pain following the activity iii. Usually intraarticular iv. Usually found with either a bone scan, CT scan, or MRI v. Early diagnosis is important to prevent a complete fracture and an eventual nonunion v. Treatment is a BK non-weight-bearing cast for 4-6 weeks if nondisplaced, and if displaced ORIF with a BK non-weight-bearing cast for 6-8 weeks NOTE* Watson-Jones navicular fracture classification described 3 types: Type 1 (tuberosity fx), Type 2 (dorsal lip fx), and Type 3 (transverse body fx)

and a fibrous articulation with the navicular) b. Anatomy: a. Type 4: Indirect crush fracture or nutcracker fracture e. NOTE* Avulsion fractures of the cuboid must be differentiated from os cuboid secondarium. Due to axial rotary forces while the foot contacts the ground in a plantarflexed position. Type 3: Body fracture. Classification system: a. nondisplaced d. b. os peroneum and/or os vesalianum d.Cuboid Fractures The cuboid is a key bone in the rigid lateral column of the foot. Avulsion fracture of the tuberosity due to tension on inferior calcaneocuboid ligament. Treatment is closed reduction with casting 4. The arterial supply is made up of an arterial rete system supplied by the lateral malleolar artery. Primarily cancellous c. c. Dorsally. Avulsion Fractures: a. the lateral tarsal artery and the arcuate artery 2. Adduction of the cuboid on the calcaneus will result in avulsion due to tension on lateral calcaneocuboid ligament. Type 6: Direct crush 3. Fractures of the body of the cuboid: a. Type 1: Stress fracture b. calcaneus. Type 2: Avulsion fractures (a) Bifurcate ligament area (b) Tarsometatarsal ligament area c. the long and short plantar ligaments attach to and cross the cuboid while adding to the maintenance of the longitudinal arch f. the dorsal tarsometatarsal ligaments attach the cuboid to the metatarsal bases e. Dorsolaterally. The cuboid is locked in articulation with 5 bones of the foot (4th and 5th metatarsals. the bifurcate ligament attaches the calcaneus to the cuboid. lateral cuneiform. Type 5: Plantar dislocation f. The peroneus longus courses plantarly under the peroneal groove in the cuboid h. the dorsal cuneocuboid ligaments tether the cuboid to the lesser tarsus d. Its position is stabilized by several structures to ensure its structural and functional integrity 1. The sural nerve and lesser saphenous vein cross over the cuboid area g. Plantarly.usually associated with fracture of the base of the 5th . Most common on the lateral aspect at the calcaneocuboid joint and the 5th met-cuboid articulation.

Treatment is closed reduction with BK cast 6-8 weeks or arthrodesis in case of crush fracture 5. Crush fracture as above mechanism but with more force (a nutcracker effect) c. b.metatarsal and calcaneus b. Should be suspected if concerned about peroneus longus tendonitis. Treatment: BK cast 6-8 weeks (first 2 weeks NWB) . dropped cuboid. Stress fractures: a. calcaneocuboid arthritis. and capsulo-ligamentous strain in the cavus foot type.

Avulsion fractures: a. Type 5 dislocations must be reduced. Stress fractures: a. therefore. with the lesser metatarsals displaced laterally and dorsally c. Fractures of the body: a. open reduction is advised. CT. and 3 injuries is usually NWB BK cast for 6-8 weeks. with any ankle inversion injury. Cuneiform fractures are usually associated with Lisfranc dislocations b. Avulsion fractures are sometimes opened if the dislodged fragment is felt to be intraarticular or will cause impingement on the peroneal tendons. or tomography b. 2. with closed reduction under general anesthesia attempted first with an inversion-adduction force on the forefoot while pushing the cuboid up from the arch. This is the Stewart Classification . Mechanism: Either by direct trauma or rotational force 3. Fracture of the 2nd metatarsal base is an important factor in causing dislocation or fracture of the middle cuneiform d. Treatment: Requires traction to reduce the dislocation and allow anatomical reduction of the cuneiforms to prevent chronic pain and arthritis NOTE* a. If this fails. Treated with BK WB cast 4. the 5th metatarsal base should always be evaluated. treatment for type 1. The mechanism of the dislocation and fractures of the cuneiforms involves the forefoot and rearfoot acting as levers.NOTE* In general. Type 4 fractures usually require autogenous bone grafting for anatomic alignment of the calcaneocuboid and tarsometatarsal joints Cuneiform Fractures 1. Diagnosed by bone scans. Usually located on the medial aspect of the internal cuneiform as an avulsion due to pull of the tibialis anterior 2. Lisfranc's ligament interruption has an effect on a middle cuneiform fracture/dislocation Fifth Metatarsal Base Fractures Fractures of the 5th metatarsal are commonly associated with inversion sprains of the ankle.

or If displaced. This is an unstable fracture with a very poor blood supply and because of this. A result of shearing force caused by the internal twisting of the forefoot while the peroneus brevis is contracted b. then ORIF 2. the fracture is extraarticular. Treatment is with an Unna-type boot or BK non-weightbearing cast for 4-6 weeks.1. Usually oblique or transverse in nature b. Type 2: Intraarticular fracture of the 5th metatarsal base with one or two fracture lines a. then ORIF 3. The mechanism of injury is primarily a sudden sharp contraction of the peroneus brevis when the ankle is in plantarflexion b. and the fracture line is usually at right ankles to the long axis of the metatarsal base a. Upon physical examination. Situated at the distal end of the articular capsule above the intermetatarsal ligaments c. or if nonreducible. This is oftentimes mistaken in the literature for a Jones fracture. The capsule is only stretched and the peroneus brevis takes practically no part on the injury d. Type 3: This is an avulsion fracture of the base of the 5th metatarsal a. The mechanism of injury is internal rotation of the forefoot while the base of the 5th metatarsal remains fixed. extreme mobility of the shaft of the 5th metatarsal is found e. this fracture has a very high propensity for non-union f. The treatment is with an Unna-type boot of BK non-weightbearing cast for . It is the most proximal injury. where a small fragment is torn away. Treatment is with a non-weight-bearing cast BK cast for 4-6 weeks. Displacement of the fragments depends upon the extent of the damage to the capsule and ligaments c. Type 1: A true Jone's fracture which occurs between the epiphysis and diaphysis (metaphyseal level). a.

a. Treatment is an Unna-type boot or a BK non-weight-bearing cast for 46 weeks. Classification: a. Greenstick fracture iv. Epiphyseal ii. The treatment is a BK non-weight-bearing cast for 4-6 weeks Metatarsal Fractures (1st and 2nd-3rd-4th) 1. There is a high rate of non-union c. Spiral . or if fracture fragments are severely displaced. Complete separation iii. Transverse ii. Diaphyseal iii. The mechanism of injury is similar to Type 2. where there is a partial avulsion of the epiphysis with or without a fracture line or hairline crack as seen in Type 2. Type 5: A fracture that occurs in children. Metaphyseal b. If the fragment is too small for fixation. Incomplete separation of the bony fragments ii. Site: i. Buckle type fracture c.4-6 weeks. This fracture can also be classified as a Salter-Harris I. Type: i. Configuration: i. Type 4: This is a comminuted intraarticular fracture of the 5th metatarsal base a. then excision of the fragment and reattachment of the peroneus brevis tendon is recommended 4. but in this case the 5th metatarsal base gets crushed between the cuboid and the ground causing fragmentation b. bone grafting and ORIF may be required 5. or if nonreducible then ORIF with tension bend wiring or screw fixation.

spiral. Displaced:  Shifted sideways  Rotated  Distracted  Overriding  Angulated  Impacted e. avascular necrosis. physis. Stress fracture d. Simple ii. epiphysis. Oblique iv. K-wires iii. Monofilament wire ii.7 cm proximal to the head of the 1 st metatarsal (on the lateral aspect) is the foramen for the nutrient artery . Relationship of the fragments: i. compression. 2. Treatment: comminuted a. metaphysis. and fluid replacement as necessary 1. Extent of the fracture: complete or incomplete 2. Open reduction: i. shock etc) tetanus prophylaxis. Comminuted v. fractures of long NOTE* Salter devised a classification system describing rigid reductionbones of fracture. Arrangement of the fracture: transverse. wound is open treat accordingly :(check blood loss. intraarticular 2. and intramedullary sclerosis 3. antibiotic therapy. nondisplaced ii. Location of the fracture: diaphysis. 3. skin coverage as necessary. and malposition NOTE* Radiographic diagnosis of this fracture should not be confused with the normal apophysis present in children (closed b age 15 in boys and 12 in girls).iii. oblique. and distally with the base of the proximal phalanx of the hallux ii. First metatarsal fractures: a. Articulates laterally with the 2nd metatarsal. AO technique NOTE* Complications include pseudoarthrosis. thickening of the lateral margin of the cortex adjacent to the fracture with or without callus. and Iselin's disease (osteochondrosis) Also differentiation should be made between an avulsion fracture and an os vesalianum and os NOTE* Radiographic evidence of chronicity is manifested by a wide perineum radiolucent fracture line. Anatomy: i. Relationship to outside environment: i. Compound NOTE* If. periosteal reaction. proximally with the medial cuneiform. Closed reduction with BK NWB cast 4-6 weeks b.

Salter classification is based on 6 categories i. Simple fractures with no displacement are treated NWB BK cast for 6-8 weeks ii.iii. bipartite indicating multiple ossification centers) v. etc. Plantar surface is concave. oblique. rotated. c. Muscles around the 1st metatarsal:  Peroneus longus: involved in 1st metatarsal base avulsion fractures  Tibialis anterior  EHL  EHB  Adductor hallucis  Abductor hallucis  FDB  Tibialis posterior vi. causing this side to be under tension during weight bearing iv. iii. Open or closed iv. spiral. Extent: complete or incomplete vi. Arterial supply is the dorsalis pedis and 1 st plantar metatarsal b. angulated. Site: anatomical location ii. the tibial being larger separated by the crista or central ridge (if more than 2 sesamoids. Treatment: i. Holds the sesamoids. Location v. Classification: a. Displaced fractures should be anatomically reduced (usually open reduction ORIF) iii. Relationship of the fracture fragments to each other: displaced. Configuration: transverse. Open fractures: treated as per open fracture classification . etc.

This supplies rigid fixation giving stability to the fracture and can be combined with other forms of fixation c. External fixator device for metatarsal fractures: A miniature external fixation device can be utilized in the treatment of metatarsals.4. Internal metatarsal fractures (metatarsals 2-3-4): Treated like the other metatarsal fractures . Maintains the normal metatarsal parabola pattern a. Indications: When a metatarsal fracture is severely comminuted or when a significant loss of bone stock is present (gunshot) b. Should be reserved for patients for whom reduction by any other means cannot be obtained 5. It is capable of both compression and lengthening the metatarsal fragments and can be combined with bone grafting as needed d.


A: Is a diaphyseal fracture with straight plate fixation without lag screw B: is a diaphyseal/metaphyseal neck fracture with application of L plate with lag screw fixation C: Is a metaphyseal base fracture with application of T-plate with lag screw fixation .

Lauge-Hansen: A two-word description indicating the position of the.F.T. i. NOTE* Healing is more favorable with supination injuries (less overall damage) . Supination-Adduction: i. b. concomitant damage to the tibiofibular syndesmosis with fracture of the medial and lateral malleolus.Ankle Fractures 1. NOTE* The hallmark of this injury is an avulsion fibular fracture at the level of the ankle or below. Supination-Adduction ii. Type B: At the level of the joint iii. Supination-External Rotation iv. with damage to the lateral collateral ligament. and posterior syndesmosis. the sequence the x-rays by anterior syndesmosis. the progression of lesions simply follows the anatomic sequence around the ankle joint: deltoid-medial malleolus complex. Stage 1: Transverse fracture of the lateral malleolus usually below or at the level of the ankle mortise or lateral collateral ligamentous rupture (pulloff) ii. Pronation-Dorsiflexion NOTE* The major advantage of the classification is to enable the examiner to assess the stability of the ankle fromstarts with the predicting In supination injuries. with the deltoid-medial malleolus complex. avulsion fracture of the lateral malleolus proximal to the A. Classifications: a. Type C: Above the level of the joint 2. Lauge-Hansen: a. and the direction of the talus. fibula. Five types of injuries listed: i. Stage 11: Stage I plus an oblique fracture of the medial malleolus (pushoff) NOTE* Variants of Stage If S -A injuries are: rupture of the deltoid ligament rather than fractures of the lateral malleolus. foot at the time of injury. DanisWeber: Based on the location of the fracture of the fibula and is useful for determining the appropriate form of treatment for ankle fractures. S-A fracture of the medial malleolus without injury to the lateral side. and in pronation In external rotation injuries. Pronation-External Rotation v. Type A: Below the joint level ii. ligamentous injuries injuries. anterior syndesmosis. Pronation-Abduction iii.

Stage . Stage I: Fracture of the medial malleolus or tear of the deltoid ligament ii. Stage III: Stage II plus an oblique supramalleolar fracture of the fibula (the anteroposterior tibiofibular ligaments tear but the interosseous ligament does not) c.b. Pronation Abduction: 1. with fracture of the posterior lip of the tibia iii. Supination-External Rotation: NOTE* This is the most common fracture of the ankle. Stage II: Stage I plus rupture of the anterioinferior tibiofibular and posterioinferior tibiofibular ligaments and transverse tibiofibular ligament. and its hallmark is a spiral fracture of the fibula i.

iii. Stage II: Stage I plus a tear of the anteroinferior tibiofibular ligament and interosseous ligament. iii. . fibula: Wagstaff) ii. Stage IV: Stage III plus a fracture of the medial malleolus d. Stage III: Stage II plus an interosseous membrane tear and a spiral fracture of the fibula 7-8 cm. Stage I: Fracture of the medial malleolus or a tear of the deltoid ligament. (tibia: Chaput. Stage III: Stage 11 plus a fracture of the posterior lip of the tibia (Volkmann's fracture) iv. i. proximal to the tip of the lateral malleolus iv. Stage IV: Stage III plus a fracture of the posterior lip of the tibia. Pronation-External Rotation: NOTE* 'The hallmark is a high fibular fracture. ii. sometimes with avulsion of the bony fragment between the tibia and fibula.I: Rupture of the anteroinferior tibiofibular ligament. Stage II: Stage I plus a spiral oblique fracture of the lateral malleolus.

if the talus is in neutral position upon impact. Stage I: Fracture of the medial malleolus ii. posterior portion of the tibial plafond fractures c. anterior portion of tibial plafond is fractured b. if the talus is dorsiflexed upon impact. which will result in the following fractures of the tibial plafond: a. Pronation-Dorsiflexion: i. Stage Ill: Supramalleolar fracture of the fibula (transverse) iv.e. Stage II: Fracture of the anterior inferior aspect of the tibia iii. axial compression is present. central shattering of the articular surface of the tibial plafond takes place . Stage IV: Fracture of the posterior aspect of the tibia (Pilon fracture) Reudi and Allgower divided these into:  Grade I: Cleavage fracture of the distal tibia with no disruption of the internal surface  Grade II: Internal surface disruption with no comminution  Grade III: Impaction and comminution NOTE* In a fall from a height. if the talus is plantarflexed upon impact. where there is pronation-dorsiflexion injury.


Frost.3. Type Il: Oblique fracture with fragment remaining attached to the IATF ligament iii. medial malleolus. Shepherd's fracture: Fracture of the posterolateral tubercle of the talus. Other fractures: a. Bosworth fracture: Fibular oblique fracture caused by external rotation but the fracture occurs after posterior dislocation of the fibula. i. It is associated with a vertical fracture of the medial malleolus. f. Type B (Supination-external rotation or Pronation-abduction LaugeHansen): An avulsion fracture of the medial malleolus and fracture of the fibula that begins at the level of the tibial plafond. This causes closed reduction to be impossible. associated with tibiofibular diastasis. b. Type l: Avulsion fracture and fibular fragments remaining attached to the anterior talofibular ligament and IATF ligament ii. Pankovich classification of Wagstaff fractures: i. and attached fibula. The posterior rim of the tibia might also be fractured c. Type C (Pronation-external rotation Lauge-Hansen): Characterized by rupture of the syndesmosis and a fibular fracture that is located above the tibial plafond. Danis-Weber fractures: a. Pott's Fracture: A fracture of the distal fibula and disruption of the deltoid ligament (or medial malleolar fracture) h. epiphysis. d. Cooperman's fracture: This is a Salter-Harris triplane type 4 epiphyseal ankle fracture which consists of 2 fragments: the first is composed of the tibial shaft. Chaput's tubercle: The anterolateral tubercle of the distal tibia j. and tibiofibular diastasis. Type A (Supination-adduction Lauge-Hansen): The fibular fracture occurs below the level of the tibial plafond and therefore below the level of the syndesmotic ligaments. Tillaux fracture: Fracture of the anterior tubercle of the tibia due to tension of the IATF ligament. fracture: A triplane fracture which is a combination of Tillaux and Salter-Harris Type 2 occurring at the distal tibia g. fibular shaft. the second consists of the remainder of the metaphysis. medial malleolus. Type III: Oblique fracture of the fibula in addition to a fracture of the anterior tibial tubercle e. Associated injuries are an avulsion fracture of the medial malleolus or deltoid ligament rupture and a large or small posterior malleolar fracture. k. Wagstaff-Lefort fracture: Vertical fracture of the anterior margin of the lateral malleolus due to an avulsion of either the anteroinferior tibiofibular or anterior talofibular ligaments. c. Maisonneuve fracture: Fracture of the proximal fibula . Volkmann's fracture: A fracture of the posterolateral corner of the distal tibia (Volkmann's triangle). Also a type 3 epiphyseal injury of the anterolateral distal tibia. 4. b. and the anteromedial portion of the epiphysis. .

which are present in some indirect ankle fractures. Early ORIF reduces swelling by stabilizing the fracture and also reduces bleeding. Absolute criteria: i. Reduction must be maintained while the fractures are healing iv. which tends to displace laterally and pull along the medial malleolus. Large displaced fragments of the anterior and posterior processes of the tibia. ORIF of the fibula should precede fixation of the medial malleolus because it provides a buttress to the talus. Early ORIF should be done provided that the initial evaluation of the patient reveals a satisfactory . In general. and ORIF as indicated. Fractures and dislocations must be reduced immediately ii. Motion of the joints should be started as soon as possible c. 4. If the fracture is open. the best long term results in terms of restoration of function and avoidance of posttraumatic arthritis are directly related to treatment that restores anatomy and allows for early range of motion and early weight-bearing. Fracture of Chaput tubercle and Wagstaff fractures should always be reduced and fixed v. A displaced yet essentially intact fibula requires syndesmotic screws for proper reduction . Closed reduction of displaced ankle fractures rarely accomplishes restoration of normal anatomy without repeated forced manipulations. lateral or posterior displacement of the lateral or medial malleolus b. should be anatomically reduced (if at least 1 /4th the weight-bearing surface) in order to restore congruity of the articular surface (reduction of these fragments prevents subluxation of the talus) iv. Shortening of the fibula must be prevented (see chapter 29: Ankle Conditions. followed by wound debridement. All joint surfaces of the ankle must be anatomically reduced iii. and should be reserved for more severe injuries in which soft tissues around the ankle are damaged. The wound is left open and delayed primary closure is performed at least 5 days later. Thurston-Holland sign: The spike of metaphyseal bone attached to the fractured epiphysis seen with Salter-Harris 2 fractures. and does not allow for early ambulation and range of motion. Ashurst's sign is present with a lessening of this overlap due to widening of the ankle mortise due to disruption of the anterior tibiofibular ligament m. General considerations: A decision to perform surgery takes in account all aspects of the patient's condition.neurovascular status and skin condition of the foot. Repair of the deltoid is difficult and rarely necessary.l. Nonunion of Malleoli) ii. irrigation. Ashurst's sign: The overlap of the anterior tibial tubercle and the medial 2/3 of the distal fibula normally is found on the A-P x-ray of the ankle. Treatment of ankle fractures: a. iii. the wound should be cultured and broad spectrum IV antibiotics started. NOTE* ORIF is indicated for all ankle fractures with a greater than 2 mm. Other criteria: i.

Closed reduction is acceptable in fractures when open reduction is contraindicated (vascular compromise. . When drilling for a syndesmotic screw. the direction must be anteromedial to avoid inserting the screw posterior to the tibia d. posterior tibial tendon into the displacement of the fibula.0 mm cancellous screws should be used for fixation of the medial malleolus (self-tapping 4. Closed reduction is contraindicated in unstable ankle fractures in which both malleoli are fractured iii.NOTE* Stability of the syndesmosis is tested by pulling the fibula laterally with a bone hook. neglected open fractures.of lateral NOTE* Observe for more than 2-3 mm i. Fixation of the medial malleolus: Requires fixation with a device that provides compression between the fracture fragments I. instability is present and the use of a ankle joint syndesmotic screw(s) is indicated. When there istendon dislocations. Closed reduction: i. pyoderma. The main advantage of closed reduction is lack of postoperative wound complications ii.5 mm malleolar screws are not practical because the head of the screw is too large and prominent after insertion)  A screw usually 40-45 mm in length is usually used  In osteoporotic bone a washer would be used to prevent penetration of the head of the screw head  A second screw is used when the malleolar fragment is large (a K -wire can be used first to prevent rotation of the fragment and retained for additional stability) f. AO technique:  Essentially only 4. it is critical to reduce the fracture anatomically in order to avoid penetration outside the bone e. AO Technique: Interfragmentary screws are inserted most often from the anterior edge in a posteroinferior direction  Overdrilling is unnecessary and may cause comminution of the fragment  3.5 mm cortical screws are most often used ii. Inyo Nails:  Excellent for transverse fractures of the distal fibula  Useful in osteoporotic bone but requiring cerclage wiring of an oblique fracture of the fibula prior to insertion  When inserting the nail. Cerclage Wiring:  It is useful in comminuted fractures while a plate is being applied to the lateral side of the fibula  Can be used as an adjunctive device for an oblique fracture of the fibula while an intramedullary nail is being used iii. When there is a plate attached to the fibula. It is desirable to insert this screw 2-3 cm above the tibial plafond.e. Fixation of the fibula: Should be fixed prior to the medial malleolus i. one cortical screw can be removed and replaced with a syndesmotic screw.

Dislocation and fracture-dislocation of the fibula behind the tibia . Gravity is utilized by positioning the leg horizontally and in external rotation while holding the foot in one hand with the heel resting in the palm. Interpositon of the deltoid ligament b. Factors that result in irreducible fractures: a. Trapping of the medial tendon(s) d. then is extended to a long leg cast with the knee in 30° of flexion. This effectively produces internal rotation and adduction of the talus and in that way reduces the fibula and brings in position the medial malleolus  A short leg cast is first applied while the fracture is being reduced. Trapping of the tibialis posterior tendon c. A minimum of 6 weeks of immobilization is required necrosis or contusion) iv.


Lateral ligament (chronic thickening. Infection following open fractures (5-30%) h. Bony complications of fractures and dislocations of the ankle: a. ORIF must be delayed for 3-7 days d. Medial deltoid ii. inversion instability. anterior subluxation) 7. DVT's: Due to plaster immobilization. Avascular necrosis of the talus g. rigid internal fixation and early ROM c. sickle-cell. Tendon injuries k. Fractures of the posterior tibial margin: Greater than 25% margin renders the ankle unstable leading to posterior subluxation i. Massive Edema: Treat with compression immediately. Chondrolysis of the ankle (cartilage necrosis): Leads to posttraumatic arthritis f. Skin: Blistering. Non-union: More common than the lateral malleolus due to soft tissue interposition between the fragments  Chronic diastasis  Loose bodies  Arthritic changes c. Nerve disruptions (complete and incomplete) ii. Treat casted patients with sub-Q heparin 2500-5000 units Q 8-12 hours if they are at risk e. local tenderness. Nerve injuries i. Fractures of the lateral malleolus: i. 2nd only to plafond injuries. Fractures involving the distal tibiofibular syndesmosis: i. venous insufficiency. elevation. Fractures of the medial malleolus: i. slow wound healing b. Varus or valgus deformity ii.6. Articular incongruity is the main concern . Articular incongruity f. Vertical or Pilon fractures of the distal tibia: i. Malunion with posterior subluxation  Most common complication d. Reflex sympathetic dystrophy syndrome i. Arterial injuries j. Mortise widening e. Fracture blisters: Direct result of edema. Epiphyseal injuries: i. Non-union and malunion (external rotation) with chronic swelling and widening of the ankle b. cold application. Posterior subluxation  Medial and lateral malleoli and syndesmosis torn ii. decubitus breakdown. Ligament injuries i. Traumatic arthritis iii. leads to arthrodesis of the ankle ii. Soft tissue complications of fractures and dislocations of the ankle: a.

a. and cuboid chip fractures also present dorsally. Usually associated with open wounds 2. Treatment: a. Result in dorsally dislocated talus and calcaneus relative to the navicular. or cuboid ii. Medial force injuries: reduced by traction and reversal of the mechanism of injury with casting (WB or NWB) b. Medial force results in three grades of injuries: i. C-C fusion is recommended for persistent symptoms. Varus or valgus deformity of the ankle v. Injuries are rare 1. Angular deformity vi. Leg length discrepancy vii. talus.ii. dorsal chip of the talus or navicular. Lateral force injuries: closed reduction first. Posttraumatic arthritis iv. Fracture of the navicular takes place c. Bone and joint sepsis Midtarsal Joint Dislocations The talonavicular and the calcaneocuboid joints function as a single unit in movements (functions with STJ in inversion and eversion) so are considered together as the MTJ. Fracture sprain of the navicular tuberosity. Swivel dislocation with only the T-N joint dislocating b. Lateral force injuries: i. and lateral fracture of the cuboid ii. Classification (Main and Jowett): Midtarsal joint injuries are defined according to the direction of the force producing the dislocation. Fracture sprain of calcaneus. Plantar force injuries: i. Vascular embarassment iii. as well as anteroinferior calcaneal fractures e. Longitudinal force injuries: i. Crush injuries: Have variable patterns. Fracture/subluxation or dislocation with medial subluxation or dislocation of forefoot while the talocalcaneal relationship remains normal iii. Triple arthrodesis has been the traditionally recommended treatment if conservative care has failed Tarsometataral Joint Dislocations/Fractures (Lisfranc dislocation) . Fracture/subluxation will result in T-N lateral subluxation and nutcracker fracture of the cuboid iii. Swivel dislocation with the talus dislocating laterally relative to the navicular d. navicular.

which are also associated with injuries to the cuneiforms. Type A: Total incongruity ii. Type 131: Partial incongruity. but a ligament extends from the medial base of the 2nd metatarsal obliquely to insert into the medial cuneiform. e. c. Angulation of the metatarsals can occur without apparent fracture at the base. lateral metatarsals iv. 2. Type B. Type C: Divergent (the 1 st metatarsal is displaced medially and the other metatarsals are displaced laterally) b. al. Type Cl: Partial displacement vi. Diagnosis: Via x-ray (A-P & lat)/tomography (A-P)/CT scan a. There is no ligament between the base of the 2nd and 1st metatarsals. and the navicular. Type B2: Partial incongruity. cuboid.This type of injury occurs in conjunction with high energy trauma (equestrian injuries) as well as minor twisting injuries. Quenu and Kuss c. i. Classifications: a. d. Partial incongruity ( at least one of the tarso-metatarsal joints is not displaced) iii. Type C2: Total displacement 3. An avulsion fragment referred to as the "FLECK SIGN" is often present between the base of the 1st and 2nd metatarsals or middle and medial cuneiforms. Myerson: Further subdivided Hardcastle's classification i. Abduction and plantarflexion: 2nd metatarsal is fractured. Projected lines from the base of the metatarsals should not intersect the corresponding cuneiforms or cuboid. the remaining ligaments give way and the forefoot is subluxed laterally b. This widening can also be between the base of the second and third metatarsals or middle and lateral cuneiforms. there may be a nutcracker-like fracture of the cuboid. Widening between the base of the 5th metatarsal and the cuboid can . medial metatarsals iii. b. which is surrounded by 5 adjacent bones that create a tight mortise. Mechanism of injury: a. Type C: Divergent patterns v. Soft tissue loss and vascular impairment can be a major problem in this setting The 2nd metatarsal is the key to stability of Lisfranc's joint. Widening between the base of the 1 st and second metatarsals or the middle and medial cuneiforms is often present. The dorsal tarsometatarsal ligaments are weaker than the plantar tarsometatarsal ligaments. 1. Type A: Total incongruity (the metatarsals displace in a unit in one plane ii. With continued abduction. Hardcastle et. The key to understanding this injury is the structural integrity provided by the slotting in the base of the second metatarsal.

With severe joint comminution. then pinning (open or closed) is mandatory followed by casting. immobilizing the extremity in a BK NWB cast is appropriate. closed reduction and percutaneous pinning. Treatment: Includes splinting. NOTE* Due to the spontaneous relocation that this fracture dislocation can produce.occur. primary arthrodesis may be considered . then open anatomic reduction with heavy gauge K wires or screw fixation is the procedure of choice. casting. closed reduction and casting. b. c. d. If severely unstable. x-rays do not usually show the true magnitude of the severity of this injury 4. or open reduction and percutaneous pinning (according to type) a. If instability is present but alignment is anatomic with release of the force. If instability is present and alignment is not anatomic with release of force.

Type B2: 1 wire laterally d. the 2nd pin should go across the 3rd and 4th tarsometatarsal joints. Type C: 3 or more wires The medial pin should go across the 1st metatarsal-cuneiform joint. The pins should remain in place for a minimum of 6 weeks NOTE* Always pin the 2nd metatarsal base . Type A: 2 Kwires (medial and lateral) b. Type B 1: 2 medial K-wires c.NOTE* Pin placement according to Myerson classification type: a. and a 3rd pin across the 2nd ray articulation.


Inversion of the ankle is resisted primarily by the ATFL when the ankle NOTE* is plantarflexed and by the CFL when the ankle is dorsiflexed. 67% water b. The posterior talofibular ligament functions to reinforce the ankle joint and the calcaneofibular ligament functions to resist adduction forces. all the other metatarsals will follow if there is no damage to the intermetatarsal ligaments 5. plantarflexion. The angular relationship between these two lateral ligaments is very d cult to attain during reconstructive ankle stabilization repair tending to cause a decrease in allowable STJ supination at the expense of attaining stability against inversion stress. elastin. Post-traumatic arthritis Ankle Inversion Sprain Also see Chapter 29. 1. Ankle Conditions: Chronic Lateral Ankle Instability Definition: A sprain is a disruption of fibers. so that if the 2nd metatarsal relocates. The anterior talofibular ligament resists internal rotation. 2. Anterior talofibular (ATFL) (intracapsular): The primary stabilizing structure preventing anterior displacement of the talus (fan shaped). NOTE* Angular relationships between the ATFL and the CFL is 100° in the frontal plane and 105° in the sagittal plane. Lateral talocalcaneal ligament NOTE* PTFL is 20-45° posteroinferior to the fibular bisection so allows STJ range of motion. Thrombophlebitis d. and glycosaminoglycans . Remaining 33%: 90% collagen type 1. ii. Complications: a. Lateral ligaments: i. Posterior talofibular (PTFL) (intracapsular/extrasynovial): The thickest and strongest and the least likely to be injured iv. Calcaneofibular (CFL) (extracapsular) iii. Sepsis c. a strain is plastic deformation with elongation Inversion sprains by definition involve lateral ligament disruption. Compartment syndrome e. Amputation b. and anterior subluxation of the talus. Neuroma formation (either traumatic or postsurgical “amputation” type) f. This sagittal plane angle decreases with STJ supination and increases with STJ pronation. Anatomy: a. Ligament composition: a.NOTE* Most feel that stability and anatomic reduction depends upon the 2nd metatarsal.

Diaz (1st word describes the position of the foot and ankle and the second word the direction of the force applied: similar to Lauge Hansen classification) i. Previous sprains (elongated ligaments no longer restrain inversion) i. 1 st degree (ATFL rupture) ii.3. and capsule rupture) iii. Plantarflexed -1st ray d. 3rd degree (all three ligaments and capsule) b. Causative Factors: a. Supination-inversion (with a plantarflexed ankle or a neutral ankle) ii. Supination internal rotation iii. STJ varum f. Mechanism of injury: a. Calcaneal varum c. Stress views (local anesthesia: peroneal block + local ankle infiltration): Can use a Telos® apparatus for better quality control i. Scout films b. and capsule or tearing of the ligaments 6. plantarflexion. Internal rotation. ankle sprains can be classified into: Type I: stretching of the ligaments or tearing of the ATFL Type II: a partial rupture or tearing of the ATFL and CFL Type III: a total rupture of the ATFL. and adduction of the talus beyond normal physiologic limits 5. Uncompensated equinus g: Muscle imbalance (peroneal insufficiency) h. Torsional abnormalities j. Diagnosis: a. Rigid forefoot valgus e. Classifications of inversion ligamentous injuries (mechanism of injuries): a. Tibial varum b. CFL. Short leg syndrome k. Inversion stress: A 5-6° difference between the injured and uninjured ankle signifies ligamentous rupture . PTFL. Ankle varus 4. Supination plantarflexion NOTE* Additionally. 2nd degree (ATFL. CFL. Leach (1983) i.

ankle arthrography would be indicated c. The patient must have no allergy to iodine ii. Stieda's process fracture (talar posterior process) c. Dye that is found within the normal anatomical confines of adjacent tendon sheaths and not within the surrounding soft tissue should be considered a normal anatomical variant d. Calcaneal avulsion of the EDB d. a negative test.NOTE* Always take bilateral inversion stress films when examining a patient radiographically with potential grade III ruptures NOTE* Degree of talar tilt is not a true indication of which ligament is ruptured ii. Push-pull stress (anterior draw sign): The ability to pull the ankle out of the mortise more than 4 mm. Talar dome fractures (medial or lateral) f. Differential diagnosis and associated findings: a. Calcaneal anterior process fracture e. Sinus tarsi syndrome g. history of chronic ankle instability. Peroneal tendon dislocations i. The injection should be administered at the anterior-medial aspect of the ankle (to prevent confusion from the actual injury) iii. Peroneal neuropathy . NOTE* For some patients there is a normal communication between the peroneal tendon sheath and the ankle joint capsule: gives a false positive 7. or inability toand to confirm ligament tears adequate possible ankle diastasis properly maneuver the uninjured ankle. Peroneal tenography: A diagnostic technique for evaluation of the calcaneo-fibular ligament. Ankle arthrography: In performing this test you must consider the following i. Peroneal stenosing synovitis h. In these cases. 5th metatarsal base fractures (avulsion and Jones) b. If dye is injected into the peroneal tendon sheath and is found to enter the ankle joint but no dye is seen in the soft tissue surrounding the ankle. usually indicates a rupture of the anterior talofibular ligament NOTE* There are certain situations where the stress test may be invalid: genetic ligamentous laxity. The test must be performed within the first 5-7 days following the injury iv. inability NOTE* The main indication for ankle arthrography in a soft tissue injury is to to achieve evaluate aanesthesia.

NOTE* A Jones fracture is a transverse fracture secondary to a triplane load with pull of the peroneus brevis .


Treatment: a. Ice iii. Definitive therapy: Either immobilization (preferred) or surgery i. Immobilization:  48 hours following the injury a BK weightbearing cast is applied for 3-6 weeks  This is followed by an Aircast® for an additional 3 weeks (for athletes this is continued for 6-9 weeks)  Stress x-rays should be repeated in 6 months to evaluate the treatment ii. patients with a significant medical history which would contraindicate more definitive therapy.. Weight-bearing to tolerance v. geriatrics with a sedentary lifestyle. Physical therapy (proprioceptive excercises and strengthening) NOTE* TEMPER is an acronym for ankle sprain rehabilitation: T: Timely diagnosis/temporary immobilization E: Edema reduction M: Muscle strengthening P: Proprioceptive excercises E: External stabilizing devices R: Return to activity b. Symptomatic therapy: Used for patients with negative stress x-rays. Elastic compression ii. i. Surgical treatment 2-3 days following injury (must be young and athletic who need complete stability): .8. Analgesics iv. and patients who present to treatment 3-4 weeks following injury.

Dislocation of the talus d. which is passed through the fibula from anterior to posterior through a flap in the calcaneus. Lee Procedure (modified Watson-Jones)*: This uses the peroneus brevis tendon. Avulsion fractures of the posterior aspect of the talus h. back through the fibula. after passing through the neck of the talus. through the calcaneus. Avulsion fracture of the lateral malleolus . Inversion injuries can result in the following: a. back through the same drill hole. from anterior to posterior. which passes through the fibula from posterior to anterior. Single ligament rupture: Watson-Jones*: This uses the peroneus brevis. and tied onto itself. Fracture of the cuboid j. Chrisman and Snook*: This uses the split peroneus brevis. which is then passed through the fibula. through the neck of the talus from dorsal to plantar. Stroren Hambly Winfield Gschwend-Francillon  Triple ligament rupture: Spotoff Rosendahl and Jansen 8. Avulsion fracture of the base of the 5th metatarsal i. Storren Nilsonne Pouzet Haig Castaing and Meunier Dockery and Suppan  Double ligament rupture: Elmslie*: Originally described as using the fascia lata and passed through a drill hole in the lower aspect of the fibula. Shear fractures of the head of the talus medially f. and is then sutured back to the peroneus brevis tendon. Osteochondral fractures of the talar dome e. and then sutured back onto itself. Sprains of the STJ ligaments b. Shear fractures of the navicular laterally g. from posterior to anterior. Evans*: This utilizes the peroneus brevis through an oblique hole through the fibula sutured back onto the belly of the peroneus brevis. Medial STJ subluxation c. and sutured back onto itself.

Rarely. Late complications of surgical repair result from overzealous tightening of the lateral ankle structure (grade III ankle sprains should be fixed in neutral not in eversion f. causing permanent neurotmesis of the intermediate dorsal cutaneous nerve and producing a profound lateral foot and ankle sensory loss d. fascicular interruption may occur. Painful sinus tarsi can occur later from an everted ankle position . Complications: a. Entrapment neuropathy ii. gangrene of the skin of the lateral ankle in cases of rupture of the perforating peroneal artery c. The most common surgical complication of primary ankle repair. Laceration e. Early complications i.9. Hematoma iii. Painful hemarthrosis ii. Inappropriate diagnosis and lack of treatment b. involves the intermediate dorsal cutaneous nerve i. Neuropraxia in grades II and III with damage to the intermediate dorsal cutaneous nerve NOTE* With greater than 20% of stretching.

A. on other assoc injury 2. Type II Anterior Talofibular Ligament Palpable tenderness Calcaneal Fibular Ligament diffuse ankle pain If plantar flexion • possible anterior deltoid ligament rupture Talar stability + Anterior drawer .Anterior drawer sign . strap (occ. W. Dap. cast) 2. K. physical therapy 3. Type I strap 2. physical therapy Syndesmotic Rare Rarely alone Abduction external rotation Edema ecchymosis -in syndesmotic area Anterior + Post Tibiofibular ligament interosseous ligament usually with Maisonneuve fracture Treatment 1. Mild -cast B. Fixation . W.LIGAMENTOUS INJURIES Lateral Common Adduction (inversion) Type I (Anterior Talofibular Ligament) palpable tenderness Talus Stable . B..possible ligament Type III AnteriorTaloflbular ligament Calcaneofibular ligament Post Deltoid if plantar flexion 1.B.X-Ray Treatment (usually occurs in young athlete) 1. W.B.Inversion stress .K. Severe. If lateral displacement of talus 2mm + Type I 3mm + Type II 4mm + Type III Treatment 1. Type III -cast B. Type II 3. K. B. youth ..X-Ray Treatment 1.Inversion stress .X-Ray (Bilateral) degree Treatment 1 strap 2 physical therapy Medial Rare Rarely alone Abduction or External Rotation Edema (occhymosis in deltoid area) Deltoid ligament ruptured to variable assesment made as per Close (1956) 1. ligament repair with cast 2. Talar stability + Anterior drawer + Inversion stress .O.. 3. Mortise view 2.

Diagnosis: a. Signs and symptoms: a. Usually closed reduction and with BK NWB cast with the foot in inversion is sufficient for 3-6 weeks. Mortise view of the ankle where the foot is abducted and everted in relation to the leg ii. Stress x-ray (local anesthesia): Can be done by hand or using a Telos® apparatus i. Deep deltoid i. Pronation-external rotation iii. Treatment: a. divided by an intercollicular groove. . Pronation-abduction 3. Calcaneotibial (strongest) iii. There is a superficial and a deep deltoid: a. followed by a BK weight-bearing cast for another 3-6 weeks. or more means tearing of part of the deltoid a. which ends structurally in two colliculi (one anterior and one posterior). Deep anterior talotibial ii. Naviculotibial ii. it is usually accompanied by other ligament injuries or fractures. Supination-external rotation ii. Deep posterior talotibial 2. b. Pain and swelling on the medial and anterior aspects of the ankle b. Since there are usually associated injuries. Mechanism of Injury: Solitary injury to the deltoid is rare. or greater is diagnostic of a complete rupture. Scout films (with pronation injuries a high fibular x-ray) b. Superficial talotibial b.Deltoid Ligament Ruptures 1. Surgical repair is indicated if closed reduction does not replace the talus to its proper position. Anatomy: The deltoid takes origin off the medial malleolus. and a displacement of 3mm. Types 5. NOTE* Most common are fractures of the fibula and ruptures of the tibiofibular ligaments of injuries: i. Superficial deltoid i. Lateral view where the foot is anteriorly displaced in relation to the leg NOTE* Stress views are done bilaterally and the clear space is what is compared Note* A clear space of 1 cm. the usual presentation is a completely edematous and ecchymotic ankle that is being splinted 4.

Physiology: At rest the intramuscular pressure is approximately 5 mm Hg. Medial compartment: Its borders are the medial and lateral intermuscular septum. Acute: Occurs when the resting pressure in the compartment exceeds the available perfusion pressure. Actual muscle necrosis is unusual 3. most commonly multiple fractures or crushing injuries. Compartments of the foot: a. Following excercise. Compartment Syndrome Usually diagnosed in the arm and leg. and within 5-10 minutes. the compartment pressure rapidly drops. the medial portion of the plantar aponeurosis. This results in a relative prolongation of the ischemic time resulting in symptoms during or following excercise. If untreated tissue necrosis is inevitable b. With a compartment syndrome. or bone must be present. Diagnosis: Measurement of an increased intramuscular pressure in the compartment via a wicks catheter (usually greater than 30 mm Hg) Two criteria must be fulfilled for this diagnosis to be made: a space that is limited by fascia. second increased compartment pressure caused by a decrease in compartment size or an increase in the size of the contents within that compartment must be present Any injury with a pressure greater than 30 mm Hg should undergo an immediate fasciotomy Note* The patient might still present with a pulse because the vascular collapse occurs first at the arteriolar level 4. also occurs in the foot. During a muscular contracture the pressure can increase up to 150 mm Hg or more. skin. has returned to baseline. It contains the abductor hallucis flexor hallucis brevis. the tarsus (proximally) and shaft of the first metatarsal (distally). or if the posterior tibial tendon gets trapped. This entity should be considered in the differential diagnosis in patients presenting with a painful swollen foot post trauma 1. the time for pressure to return to baseline is protracted. a. and the FDL tendon . This is usually the result of trauma with hemorrhage or gross muscular edema causing the increased compartmental pressure. This can eventually result in contractures and poorly functioning limbs. At relaxation. Types of compartment syndrome: a. Chronic: Occurs when the resting pressure is higher than the normal resting pressure but not so high as to cause hyperprofusion. Definition: Increased compartmental pressure resulting in decreased perfusion and ultimate ischemic changes to the tissues on the compartment. there is no drop of pressure 2.NOTE* This can occur if the deltoid gets rolled up or inverted. and can follow several types of injuries.

Comminuted fractures b. PT and peroneal tendons c. Type 1: i. the plantar aponeurosis. Intramuscular hematomas associated with bleeding diasthesis e. It contains the interossei 5. Double dorsal technique:  Midfoot and forefoot: 2 dorsal longitudinal incisions. Treatment: a. and the associated osseous components. It contains the abductor digiti minimi. Combined approach 7. Wound more than 1 cm. or short oblique with minimal comminution b. flexor digiti minimi. Fracture is simple. FDL tendon with lumbricals. The wound is closed secondarily in 5 days. adductor hallucis. Or none of the above 6. Crush injuries Open Fracture Classification System and Treatment 1. Severe soft tissue injuries c. Post-ischemia swelling d. and the level of contamination a. Minor soft tissue damage is present ii. transverse. Extensile medial incision iii. and opponens digiti d. Paresthesias c.b. quadratus plantae. Wound less than 1 cm long and clean ii. lateral portion of the plantar aponeurosis. Associated complications: a. Lateral compartment: Its borders are the lateral intermuscular septum. Pain out of proportion to the clinical findings b. flaps or avulsions . It contains the flexor digitorum brevis. Pulselessness d. Clinical Findings: a. Gustillo and Anderson described an open fracture classification system: This depends upon the mechanism of injury. Fasciotomy i. the configuration of the fracture. long without extensive tissue damage. the central portion of. the tarsus (proximally) and interosseous fascia (distally). one over the 2nd metatarsal and the other over the 4th (deepened down to the metatarsal shaft) where a hemostat is passed into each adjacent interosseous space. ii. Type 2: i. degree of soft tissue damage. Central compartment: Its borders are the medial and lateral intermuscular septum. Interosseous compartment: Its borders are the metatarsals and the interossei fascia.

and neurovascular structures. For type 3 injuries a cephalosporin plus an aminoglycoside (1. Gustillo and Anderson recommend cefazolin for type 1 and 2 open fractures (2 gm initially followed by 1 gm Q 6 hr for 3 days). aureus. musculoskeletal.R. General principles of treatment: a. Type 3A: Open fractures with adequate soft tissue coverage of bone despite extensive soft tissue laceration ii. especially if soft tissue coverage is necessary .000 units of bacitracin and 1 million units of polymyxin B in 1 liter of sterile saline. Severe contamination and severe comminution. All marginal. Moderate contamination c. f. or 50. including muscles. Usually a local or free flap is needed for bony coverage iii. farm injuries) i. e. Tetanus history and therapy administered b. Fluorescein (non-toxic dye) may be used to assess the viability of the soft tissue structures i.5 gm/kg body weight then 3 to 5 gm/kg body weight in divided doses) is used.HCT. macerated skin. with repeat debridement and irrigation in 24-48 hours NOTE* The irrigant can contain either 1 gm cefazolin in 1 liter of sterile saline. Thorough H & P conducted (blood loss measured-CBC.ii. skin. (cultures and gram stains should be taken) NOTE* The primary bacteria encountered in open fractures is Staph. There is a slight crushing injury. Appropriate antibiosis should be administered in the E. Complete x-rays d. moderate comminution of the fracture ill. Type 3B: Open fractures having extensive soft tissue loss with periosteal stripping and bone exposure. Immediate debridement and irrigation. Type 3C: Open fractures are associated with arterial injury requiring microvascular repair. regardless of the soft tissue coverage 2. the choice of antibiotic is determined by the extent of the soft tissue injury. and soft tissue should be debrided h. and vascular assessment of the lower extremities c. Penicillin is added for farm injuries to cover Clostridium sp. with a high degree of contamination (high velocity injuries. However. The wound should be kept moist and re-evaluated in 48-72 hours. All foreign debris should be excised g. Hb) with neurological. Type 3: Extensive soft tissue damage. with repeated debridements.

0 to 5. using cefazolin as above. Type 2 and 3 are treated with combined therapy.) should be used for articular and metaphyseal open fractures. Internal fixation (screws. to cover for Clostridium sp. Displaced intra-articular fractures where incongruity will lead to degeneration of the joint c. Nonunions that do not have the capacity to unite (pseudoarthrosis and avascular nonunions 4. pins. This is done preferably within 8 hours of the NOTE* An open fracture untreated in the initial 7-8 hours (golden period) is generally considered to convert from a contaminated wound to an infected wound injury 3. For type 3B and 3C open fractures.51. Major avulsion fractures with muscle ligament attachments e. the soft tissue loss is so great that the use of skin flaps is necessary and a delay in using them becomes apparent because of the repeated debridements l. followed by 3.7 mg per kg on admission. and 3A open fractures delayed primary closure. etc. accomplishes compression/reduction of the angulation/ stabilization of the fracture without much surgical trauma m. Antibiotic considerations: a. Administer 10 million units of Pen G if the injury was sustained on a farm.0 mg per kg per day in divided doses. For type 1. plus an aminoglycoside (Gentamycin or Tobramycin) dosed at 1. Type 1 fractures are treated with Cefazolin 2 gm STAT followed by 2 gm Q 8 h for 48 to 72 hours c. . Vascularized tissue will fluoresce yellow-green and nonvascularized tissue will appear dark blue j. Displaced epiphyseal fractures with a large potential for growth disturbance d. allows for grafting procedures. Limiting the duration of the initial antibiotic therapy is important to minimize the emergence of resistant nosocomial bacteria b. using skin grafts within 5-7 days k. Irreducible fractures where function and alignment can not be obtained otherwise b. External fixation should be used for all type 3 and unstable type 2 fractures The advantages of external fixators include the ease of application without additional trauma. allows for daily wound inspections and care. 2. The duration of therapy is 3 days unless overt infection develops d. plates. Absolute indications for open reduction: a.NOTE* 10-15 mg/kg of fluorescein is injected IV and observed under UV light after 10-20 minutes.

Antibiotic prophylaxis c. porcine xenografts. Debridement and copious lavage under local/regional. General protocols: a. Wound with tissue loss: Excision. Depth and extent of the wounds carefully explored and inspection with removal of all foreign bodies and all non-viable tissue and packed open f. Skin closure when appropriate 3. Tidy wound: Once debrided. Swelling within closed compartments may indicate the need for the release of damaged fascia or skin c. b. or appropriate autograft f. Treatment (specific): a. Primary wound care: remove all foreign and devitalized material copious flushing. laceration b. atraumatic tissue handling. avulsion d. Inspection of the wound under local or regional anesthesia e. lymphangitis. and urinalysis as necessary g. Tetanus prophylaxis b. avulsion. Tidy wound: Surgical incision. burn. Untidy wound: Deep damage must be repaired and skin closure should be delayed until wound demarcation has progressed to the point where viability is reasonably assured. H 8 P. CBC. Antibiotic therapy is started after cultures are taken d. musculoskeletal and integumentary status d. Infected wound: Prior to closure the wound must be debrided and converted to a contaminated wound. can be closed after appropriate skin cleansing (skin edges may be freshened) b. Infected wound: Established (cellulitis. Classification: a. The wound is reexamined under regional/general anesthesia in 24-48 . abrasion c. Secondary or delayed primary closure may be indicated. abscess. or general anesthesia e.Soft Tissue Injuries 1. Priority is given to prevention of infection especially Clostridia sp. Initial gentle cleansing of the wound with a mild soap (no strong antiseptics that can cause tissue damage) f. or vasculitis) or Incipient (bum. Untidy wound: Crush. avoid tourniquet h. and then a clean wound (check with C&S and colony counts: less than 105 bacteria per millimeter means contamination) Crush Gunshot and Lawnmower Injuries 1. neurological. ulcer. Therefore tetanus prophylaxis is given (see chapter Infectious Disease) c. X-rays. Treatment (general): a. abrasion) 2. including vascular. Wound with tissue loss: Must prevent the wound from drying out and must cover exposed vital structures using biological dressings. bum. contaminated wound.

but in compression as well. plastic deformation of bone. If no improvement in 3 days suspect a gram (-) infection e. The number 105 bacteria present in the wound is mentioned as a criteria of active infection. as adult bone. and after further debridement the wound is packed open g. acute injury can only be inferred from widening of the growth plate or from displacement of the adjacent bones on plain x-ray. General protocols: a. Hence there are certain pediatric fracture patterns: buckle fractures. Anatomic differences: Since the growth plate is radiolucent. as it has been seen on the board exams (this is unreliable) h. Tetanus prophylaxis b. Rigid stabilization of fractures Puncture Wounds These wounds deserve special attention because they characteristically have a benign presentation that can rapidly progress to OM if not treated appropriately. leave wound open. WBC to follow patient progress Epiphyseal Plate Injuries: Also see section: Pediatrics (Pediatric Fractures) 1. It also will fail not only in tension. If pain persists after 4 days of treatment use bone/gallium scans. thicker. Use xenograft as necessary to prevent further contamination i. and produces callus more quickly than in adults 2. surgical exploration and debridement are necessary f. Complications run as high as 10%. Remove all foreign material. The wound should not be closed before 5-7 days (check cultures and use clinical judgement) NOTE* The most important criterion is the clinical appearance of the wound in the decision to close a wound. Physiological differences: Growth provides the basis for a greater . Biomechanical differences: Pediatric bone is less dense. The periosteum is stronger. sed rate. Pseudomonas is the most common pathogen isolated 1.hours. If bone or joint is penetrated or if wound is deep. and greenstick fractures 3. do C&S c. Use split thickness skin flap immediately on the dorsum of the foot if the tendons are exposed without the paratenons (this is the only time immediate coverage is utilized) j. Start broad spectrum antibiotics d. more porous with a smaller lamellar content than adult bone.

no disruption of growth. Type 6: A scooping out of a portion of the growth plate. Potential for growth disturbance as the fracture line crosses the entire growth plate. but when growth is disturbed. There are 2 types of growth plates. Type 1: A complete separation of the growth plate at the zone of transformation. Any large fragments of bone are reduced. This is an example of Wolff's Law. As the germinal cells multiply. and must not be left displaced by ORIF d. the cell population of the plate increases. via some type of projectile causing osseous and soft tissue damage. Type 4: A fracture from the metaphysis through the growth plate and into the epiphysis. a fracture through the shaft of long bone stimulates longitudinal growth (increased nutrition of the growth cartilage). Anatomy: The growth plate is a cartilagenous disc situated between the epiphysis and the metaphysis. Type 3: Separation of the growth plate with extension of the fracture line into the epiphysis so that it is intraarticular. a concavity is filled out by periosteal new bone). and hyperemia producing local overgrowth. The germinal cells are attached to the epiphysis and their blood supply is from the epiphyseal vessels. Type 2: Separation of the growth plate with extention of the fracture line into the metaphysis. which can result in a longer bone as a result of a fracture. There is usually no growth disturbance and it is treated the same way as type 1 c. The plane" of separation in the physis is most frequently at the junction of the calcified and uncalcified cartilage. This fracture is unstable and requires ORIF e. Type 5: A crush type injury usually with subsequent growth disturbance. epiphyseal (those that form under pressure) and apophyseal (those that form under traction) 5. formation of a bone callus bridge between the bony epiphysis and metaphysis. Treat the bony bridge with resection and interposition of fat or silicone rubber . With an epiphyseal separation. Also. Treated with closed reduction (if displaced) and immobilization 3-6 weeks NWB f. If much of the germinal layer is disturbed. the reason is from avascular necrosis of the plate. growth may be affected 6. crushing or infection of the plate. This extension creates the 'Thurston Holland Sign'. most of the important germinal part of the plate usually remains with the epiphysis. and can result in growth disturbance. Classification: Salter-Harris a. Because of this. treated with closed reduction and immobilization for 3 weeks b. Bony bridging causing growth disturbances can be a complication here. pediatric fractures can be treated more conservatively than with an adult of remodeling than is possible with the adult (a bump of a malunion is corrected by periosteal resorption. known as the zone of transformation. Growth plate injuries: Problems after injury are rare.

Never use threaded pins or screws across a growth plate 10. Tuberosity of 5th metatarsal: Injury from direct impact or forced inversion of the foot. IV antibiotics. If the tuberosity is displaced. Very difficult to diagnosis in the very young. Fractures of the hallux: a. and follow appropriately b. Reece© shoe. Intra-articular dorsal avulsion fracture of the distal phalangeal base: i. tetanus prophylaxis. and closed reduction with immobilization for 6 weeks if stable and in anatomic alignment b. irrigate copiously. (heel lifts. Mechanism: Direct trauma ii. patient instructed to check vascular status frequently.g. Treat with immobilization if nondisplaced and ORIF if the fragment is large and displaced (or excision of the fragment if too small to reduce) 7. a Salter-Harris fracture type 1 a. Specific ankle fractures: a. Communited fracture of the distal phalangeal tuft i. An unstable fracture. ice packs If open fracture. This fracture is unique to the age group of 12-13 year olds. open drainage. Apophyseal Injuries: Either an inflammatory process secondary to traction vs. Later calf muscle stretching is helpful b. Diagnosis is made by visualizing the fracture on at least 2 views. orthoses. Calcaneal apophysitis: Involves reduction of stress to the apophysis. replace nail plate as part of compression dressing. closed reduction with immobilization for 3 weeks 8. Treatment: Always advise of the long term sequelae of the fracture 9. and local anti-inflammatory measures) with severe cases requiring BK casting. Internal fixation devices: Smooth K-wires should be employed and should be buried to avoid infection of the plate which can cause an autolysis of the plate. Triplane: A Salter-Harris type 4 fracture of the tibia. Treatment:  Local anesthesia and prep  Avulse the nail atraumatically If closed fracture reduce any gross prominences. Type 7: An intraarticular fracture that does not involve the physis. Tillaux fracture: A Salter-Harris type 3 of the tibia involving the lateral aspect of the tibia. Treatment is ORIF if displaced or unstable. debride necrotic tissue and loose exposed bone leaving no prominences. Reece© shoe. Mechanism: Forced plantarflexion of the hallux IPJ (stubbing) resulting in avulsion of the EHL insertion . requiring ORIF Digital Fractures and Dislocations 1.

2. Hallux IPJ intra-articular fractures of the distal or proximal phalanx: i. Mechanism: Direct or indirect trauma (stubbing most common) resulting in a transverse. or ORIF for gross reduction failures iii. Treatment of displaced fracture (most common): ORIF followed by Reece© shoe iii. Treatment of nondisplaced fracture: Buddy splinting to 2nd toe and Reece© shoe e. Non-articular proximal phalangeal fractures: i. Mechanism: Direct or indirect trauma resulting in a transverse oblique fracture ii. First MPJ intra-articular condylar fractures of the proximal phalanx: i. Reese© shoe for 4-6 weeks d. Treatment of displaced fracture (most common): First attempt closed reduction. Mechanism: Usually a stubbing injury with axial forces resulting in an oblique push off or comminuted fracture ii. Mechanism: Transverse plane torque resulting in avulsion of the insertion of the medial or lateral intrinsics ii. consider surgical repair. Treatment of nondisplaced fractures (common): Buddy splinting c. or BK cast (with or without percutaneous pinning) c. Treatment of displaced fracture: ORIF followed by Reece© shoe for 6 weeks (smaller fragments maybe excised and the intrinsics reinserted) iii. Treatment of nondisplaced (uncommon): Closed reduction with slipper cast. ORIF larger fragments and excise smaller fragments. If failure then primary arthroplasty. followed by buddy splinting. splinting. or at the base or epiphysis ii. mid-shaft. Treatment of displaced fracture (less common): Closed reduction followed by buddy splinting. Reese© shoe iii. If closed reduction fails. PIPJ intra-articular proximal phalangeal fractures: i.ii. Fractures of the lesser toes: a. . oblique or spiral fracture appearing sub-capitally. Mechanism: Transverse plane torque (stubbing) resulting in a push-off fracture of the medial or lateral condyle of either the distal phalangeal base or the head of the proximal phalanx ii. and if successful pad 1st interspace with felt or cotton and tape to the 2nd toe. then buddy splint to the 2nd toe. Treatment of nondisplaced: If no change in hallux abductus. if the hallux abductus changed. Treatment of displaced fracture: Closed reduction (with or without percutaneous pinning). Treatment of displaced and non-displaced fractures: Closed reduction aimed at restoring alignment. Proximal phalanx shaft fracture: i. Fractures of the distal and intermediate phalanges: Rare unless crush type b.

First MTPJ dislocation: a. Type 1:  Joint capsule torn transversely under the metatarsal neck  Proximal phalanx. 2. Type 1: Open reduction . Treatment: Ice. Mechanism: Hyperdorsiflexion b. or hyperabduction stress resulting in a . Mechanism: Hyperdorsiflexion. Classification (Jahss): i. Type 2B:  Same as type 2A except sesamoid fractures occur instead of the intermetatarsal ligament rupturing  Easier to reduce than type 1 3. Treatment of displaced fracture: ORIF depending on the size of the fragment and comminution iii. Treatment: a. Treatment of nondisplaced fracture: Reece© shoe for 6 weeks 1st MPJ Trauma 1. and sesamoids dislocated dorsally on the first metatarsal head  First metatarsal protrudes through the capsule. lateral. LO.1st MTPJ sprain without alignment changes b. Type 2A:  Same as type 1 except that rather than the entire plantar capsule and sesamoid apparatus dislocated dorsally. Turf Toe: a. Reece© shoe. Lateral. plantar axial) c. hyperadduction. modify the athletic shoe. rest. or sesamoid fracture (take MO.d. hyperplantarflexion. X-ray evaluation: Rule out dislocation. AP. X-ray evaluation: Rule out osteochondral fracture and sesamoid fracture (take AP. the intersesamoidal ligament ruptures and the sesamoids sublux to each side of the metatarsal head  Easier to reduce than type 1 iii. depressed plantarly by the retrograde forces of the hallux  Hallux IPJ is flexed  Usually not reducible by closed technique ii. plantar capsule. plantar axial) c. Mechanism: Usually a stubbing injury ii. osteochondral injury. MPJ intra-articular proximal phalangeal fractures: i.

maintaining contact with the metatarsal head b. sesamoiditis. lateral and plantar axial (MO for tibial and LO for fibular sesamoid) 75% of bipartite sesamoids are unilateral. Simple nail.NOTE* Closed reduction can be tried under anesthesia as follows: traction and increase dorsiflexion. almost never bilateral ii. and fractured sesamoid c. hypertrophic sesamoid. subungual bleeding. Malay): a. Sesamoid fractures: a. and repetitive indirect trauma (traction of the intrinsics) b. A separation of the nail plate from the bed ii. osteochondritis dissecans. Type 2A: Closed reduction followed by Reece shoe or BK walking cast c. Primary onycholysis: i. Differential diagnosis of pain in the sesamoid area: Joplins neuroma. Must check for fractures of the plate from impaction iii. Blood clot under the nail plate ii. Tetanus coverage . and digital sepsis especially in compromised patients iii. Removal of the nail plate. bed laceration: i. then push the proximal phalanx into contact with the metatarsal head. Mechanism: Fall from a height. X-ray evaluation: Order bilateral AP. Clinical presentation: Pain on direct palpation and pain on hallux dorsiflexion iii. ruptured bipartite sesamoid. and antibiotics (prn) iv. DJD/eroded crista. Classification (S. Type 2B: Closed reduction followed by Reece shoe or BK NWB cast (sesamoid may have to be excised at a later date prn symptoms) or open reduction with excision of the fractured sesamoid 3. Normal sesamoids:  Ossification appears at 8-10 years  Bipartite sesamoids more common in tibial than in fibular  Sesamoids may be multipartite Nail Bed Trauma 1. osteochondrosis. the nail plate must be removed from the tissue to decompress the area iv. Bone scan if in doubt d. antisepsis. turf toe. Drill holes can be made if feasible c. repetitive direct trauma (dancing). X-rays should be taken to r/o fracture v. Presentation: i. Sesamoid involved: Tibial more than fibular (tibial is larger). then push (don't pull) the proximal phalanx into the reduced position. No adverse sequelae b. Partial avulsions cause posterior nail fold friction injury. The nail plate can be removed if the hematoma comprises more than 25% of the nail plate vi. Treat like open fractures. rarely both injuried. Subungual hematoma: i.

Systemic antibiotics iii. Nail bed injuries are usually repaired with a 6-0 absorbable suture on an atraumatic needle vi. rotational flaps are utilized e. Plantar oblique iv. Tibial or fibular axial .ii. Nail bed laceration with phalangeal fracture: As above plus i. Tissue loss increases the likelihood of poor cosmetic result 1. Remove all bone spicules and nail fragments 2. then soaked in Betadine until the bed repair is accomplished. Classification (Rosenthal): According to the level and direction of tissue loss a. and should be considered and treated like open fractures. Widening of the nail e. Direction of tissue loss i. Zone 3: proximal to the distal end of the lunula b. Complex nail bed laceration: As above plus i. Zone 1: distal to bony phalanx ii. The root and the bed must be accurately aligned on the toe vii. Adhesions of the skin fold to the nail root c. If you are avulsing a salvagable nail plate. Split nail b. Reusing the nail plate involves scraping all soft tissue from the nail plate. Dorsal oblique ii. drilling holes through the body. Complications: a. Chronic ingrown nails d. Transverse guillotine iii. Malaligned nail Toe Tip Injuries With Tissue Loss These injuries are secondary to crush forces. Protruding or non-adherent nail g. remove it in one piece and save for subsequent splinting v. Periosteal irregularities must be debrided viii. and then the nail plate is replaced on the nail bed and anchored with Steri-strips® ix. Subungual fractures must be accurately reduced ii. Zone 2: distal to the lunula iii. Narrowing of the nail f. Level of nail bed tissue loss i. If a major segment of the proximal nail fold over the matrix is avulsed with a skin defect. Avulsive lacerations of the bed are treated with intermediate thickness skin graft d. Surgical cleansing and lavage (no epinephrine utilized in seriously traumatized digits) iv.

Coverage of nail bed and phalanx tip usually achieved by local neurovascular advancement flap c. penicillin. Occasionally skin graft large defects (split thickness less durable. dogs can also cause a crushing injury. Usually complete nail bed loss iii. Thorough and aggressive debridement and irrigation (manual lavage using Ringer's lactate or dilute Betadine®) 5. Treatment: a. Some authors believe that the culture of the bite wound offers little information because of the multiplicity of organisms found and the absence of an established infection 3. Pasturella multocida (gram negative bacillus) is present in 50% of cat bites and 25% of dog bites Other organisms should also be considered: Pseudomonas. In addition to tearing of tissue. Attempt to maintain tendon function v. Delayed revision of the digit v. then initiate ROM and adjunctive PT 6. Zone 2: i. debridment and appropriate wound closure (usually secondary intention) ii. X-rays of the involved area should be obtained 4. Terminal Symes may be necessary Dog and Cat Bites Both dog and cat bites are susceptible to infection because of direct inoculation of bacteria from the animals into the bite wound.v. so that aggressive therapy should be undertaken initially. or Augmentin® is recommended . full thickness more durable) b. 1. For cat bites. dicloxicillin. and beta streptococcus 2. Leave any potentially contaminated wound open for 4-6 days. if the wound is clean. Flush. OR debridement of necrotic tissue and matrix iv. Elevation and immobilization with the ankle at 900. Zone 3: i. The use of prophylactic antibiotics is still controversial a. Reduction of bone with debridement of necrotic tissue ii. without redness or swelling. Central or gouging 2. Not suitable to initial treatment in ER or office ii. Staphylococcus. Most patients with bite wounds harbor bacteria. Zone 1: i. it is reasonably safe to perform primary closure 7. and after 72 hours improvement occurs. and at that time.

section on Rabies . For dog bites dicloxicillin. or Augmentin® is adequate (one study showed a 95% cure of infected dog bites with cephadrine) 8. Infectious Disease. cephalexin. See Chapter 6. Rabies is of concern with any animal bite.(erythromycin in penicillin allergy) b.

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