Diagnostic imaging of trauma to the ankle and foot: I. Fractures about the ankle

Drs. Mitchell et al. provide a valuable radiologic perspective of trauma to the ankle. The review is divided into six parts. The initial presentation deals with ankle fractures. Subsequent dialogues will consist of ligamentous injuries, trauma to the talus, calcaneal fractures, midfoot, and forefoot injuries. Plain x-ray film, as well as sophisticated studies, will assist in recognizing these conditions.     

Diagnostic imaging of trauma to the ankle and foot: IV. Fractures of the calcaneus

Drs. Mitchell et al. provide a valuable radiologic perspective of trauma to the ankle and foot. This review is divided into six parts. The previous presentations involved ankle fractures, ligamentous injuries, and trauma to the talus. Subsequent dialogues will consist of midfoot and forefoot injuries. Plain x-ray films, as well as sophisticated studies, will assist in recognizing these conditions.     

Complex forefoot injuries in motorcycle couriers

We reviewed all the severe forefoot injuries admitted to two urban hospitals over a 12-month period. These included 13 tarsometatarsal injuries, of which nine occurred in motorcycle couriers. Analysis of these nine patients suggests a combination of direct trauma leading to open multifragmented metatarsal fractures, and indirect force with dorsiflexion and rotation leading to midfoot disruption. In two cases there was significant other trauma which led to delayed treatment. In six of the nine cases, inadequate footwear was noted. All the patients underwent operative reduction and stabilization, and two necessitated later plastic surgical intervention. Our review suggests that motorcycle couriers are at significant risk of severe forefoot and midfoot trauma. A high index of suspicion is necessary when such patients are admitted with multisystem injuries. Education regarding correct footwear is also warranted.     

Assessment of plantar pressure in forefoot relief shoes of different designs

BACKGROUND: After reconstructive forefoot surgery, patients require complete or partial forefoot relief, which can be obtained with a variety of shoe designs. The aim of this study was to evaluate the effectiveness of two different types of forefoot-relief shoes frequently used after surgery, especially their safety against unintentional forefoot load. METHODS: Ten healthy volunteers were asked to perform five trials on a treadmill at self-selected speeds. In the first trial, mean peak pressure values in mass-produced shoes and insoles were evaluated and considered as 100%. Two different shoe designs (short heel-short sole, ii: short heel-complete sole) were compared in two trials each with appropriate and inappropriate use (attempting to put weight on the forefoot) gait pattern. Plantar pressure values were obtained using the Pedar cable system (Novel Inc., Munich, Germany). For analysis, pedobarographic pictures were subdivided into midfoot (31% to 60% of the total insole length) and forefoot (61% to 100% of the total insole length). ANOVA was used for statistical analysis, and p values less than 0.01 were considered significant. RESULTS: With the short-soled shoe, forefoot and midfoot relief was 100% in both compliant and in noncompliant use. With wearing a complete sole, compliant use led to a significant reduction (p < 0.01) of mean peak pressure under the forefoot (34 +/- 13% remaining) and midfoot (47 +/- 13% remaining). Noncompliant use of the complete-sole shoe produced mean peak pressure values significantly higher (p < 0.01) than normal gait in mass produced shoes under the forefoot, but not under the midfoot. CONCLUSIONS: Forefoot-relief shoes are effective in reducing both mean and peak plantar pressures. Shoes with a nonsupported midfoot and forefoot may be safer with inappropriate use than shoes with a complete sole. The kind of forefoot shoe should be carefully chosen to regulate weightbearing after reconstructive forefoot surgery.     

Predictors of amputation in high-energy forefoot and midfoot injuries

IntroductionHigh energy injuries to the midfoot and forefoot are highly morbid injury groups that are relatively unstudied in the literature. Patients sustaining injuries of this region are challenging to counsel at the time of injury because so little is known about the short and long term results of these injuries. The purpose of this study was to investigate injury specific factors that were predictive of amputation in patients sustaining high energy midfoot and forefoot injuries.Patients and methods137 patients with 146 injured feet [minimum of two fractures located in the forefoot and midfoot, excluding phalanges, talus, calcaneus, with a high energy mechanism].Results121 of 146 feet (83%) were treated operatively; 27 patients sustained 34 total surgical amputation events. 30-day amputation rate was 13.9% and 1-year amputation rate was 18.9%; 27 of 146 feet ultimately sustained amputation with 23 of 27 sustaining a below the knee amputation (BKA) and 17 of 23 (73.9%) received a BKA as their first amputation. Statistically significant predictors of amputation included the number of bones fractured in the foot (p = 0.015), open injury to the plantar or dorsal surfaces of the foot, Gustilo grade, vascular injury, and complete loss of sensation to any surface of the foot (all p < 0.001). Specific fracture patterns predictive of any amputation were fracture of all five metatarsals (p < 0.001) and fracture of the first metatarsal (p = 0.003). Presence of a dislocation or fracture of the distal tibia were not predictive of amputation. Midterm patient-reported-outcomes (N = 51) demonstrated no difference in physical function for patients with and without amputations.ConclusionsHigh-energy forefoot and midfoot injuries are associated with a high degree of morbidity; 1/5th of patients sustaining these injuries proceeded to amputation within 1 year. Injury characteristics can be used to counsel patients regarding severity and amputation risk.     

Frakturen und Korrektureingriffe im Vorfußbereich

The quality of life of accident victims can be considerably dependent on the treatment of the injuries of the foot. Especially the impact of fractures and dislocations of the forefoot are often underestimated. Any dislocated fracture of a toe joint should be reconstructed and the fractures of the medial and lateral rays of the midfoot should be stabilized. Serial fractures of the central rays should be considered unstable with the necessity of stabilization. Acute or chronic dislocations of the metatarsophalangeal joint should be reduced subtly to avoid long-term damage. The reconstruction of a hammertoe may have both a cosmetic and functional dissatisfying result. The method of interpositional arthrodesis with a cancellous bone plug from the heel is a simple technique which gives excellent results. The forefoot parabola should be harmonic at the same time. Alloarthroplastic replacement of the great toe joint is primarily a simple procedure, however, if it fails, it turns into major reconstructive surgery which might require callous distraction due to a large bone defect.     

Fractures of the child's foot

The incidence of fractures of the foot in childhood depends considerably upon whether the site of fracture is the hindfoot, midfoot or forefoot. Fractures of the talus or calcaneus are rare. However, in the literature there are a significant number of publications on these fractures from the point of view of arthrosis problems or aseptic necrosis. In contrast, only few reports have been published about mid- or forefoot fractures in children. Generally, treatment problems and long-term prognosis are believed to be unproblematic. However, follow-up studies of these fractures have shown that some of them can be followed by significant disabilities concerning the plantar arch or the gait pattern. More extensive follow-up studies seem to be necessary to point out specific recommendations for treatment of foot fractures in childhood. Some of the problems are discussed in detail.     

Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury

Proximal fourth metatarsal injuries are rarely reported. We present five case histories in which athletic patients sustained injuries at the shaft-base junction of the fourth metatarsal. Similar to proximal fifth metatarsal injuries, adduction of the forefoot appears to be associated. Our patients returned to their activities in two to eight months. These patients injuries tended to take longer to heal than other lesser metatarsal fractures and stress fractures (which are typically more distal). Some patients were continually symptomatic, even after three months of rest and immobilization. This coincides with proximal fifth metatarsal injuries and stress fractures. For treatment of proximal fourth metatarsal injuries to be successful, ideal treatment appears to involve nonweightbearing below-knee cast/boot immobilization for three weeks. This is followed by an additional three or more weeks of weightbearing immobilization. Healing may still be prolonged.     

The effect of triceps surae contracture force on plantar foot pressure distribution

BACKGROUND: Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure. METHODS: Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350 N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions. RESULTS: The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p相似文献   

Midfoot fractures

Fractures of the midfoot are uncommon because of the constrained configuration of multiple articular surfaces, which is augmented by capsular attachments and strong ligaments and tendons. Injury patterns usually involve more than one structure, although isolated fractures, dislocations, and sprains can occur. The key to optimal treatment of midfoot fractures is a high index of clinical suspicion because of their rareness. The traumatic midfoot injuries described in this article are categorized as Chopart joint injuries, tarsal scaphoid fractures, cuboid fractures, cuneiform fractures, and Lisfranc joint injuries.     

Vorfu?frakturen

Fractures of the forefoot are common and comprise approximately two thirds of all foot fractures. Forefoot fractures are caused by direct impact or the effect of indirect force. The forces exerted can range from repetitive minor load (stress fractures) to massive destructive forces (complex trauma). The clinical course in forefoot fractures is typically more favourable than in fractures of the mid- and hindfoot. The incidence of complications like infection or pseudarthrosis is low. Exceptions are rare fractures of the proximal shaft of the fifth metatarsal and the sesamoids with higher pseudarthrosis rates. Malunited metatarsal fractures can cause painful conditions that should even be treated operatively. Differences in structure and function of the different forefoot areas and specific fracture types require an adapted management of these special injuries.     

Fractures of the forefoot

Fractures of the forefoot are common injuries of various causes. Although not crippling, forefoot fractures can be debilitating if they go undiagnosed or are mistreated. Whenever patients complain of foot pain with ambulation or difficulty ambulating, radiographs should be taken as part of a standard routine to assess for bony pathology. This article discusses the classification and treatment of metatarsal fractures, digital and sesamoid fractures, and open fractures about the forefoot.     

The Results of Physical,Radiologic, Pedabarographic,and Quality-of-Life Assessments in Patients with Surgically Treated Intraarticular Calcaneus Fractures

Calcaneal fractures are complex injuries and have historically had a poor prognosis that results in substantial disability. However, no studies have been performed that analyze both the radiographic and plantar pressure changes after treatment of intraarticular calcaneus fracture. Patients with an intrarticular calcaneus fracture treated at our institution during the study period were identified from computerized hospital records. A total of 36 patients (34 males) completed physical examination and radiographic and dynamic pedobarographic assessments. The follow-up period was from 13 to 82 months (median 38 months). The mean pain score at rest was 3.7 and during activity was 4.0 on a 10-cm visual analogue scale. The mean range of motion of the subtalar joint was restricted. The mean American Orthopaedic Foot and Ankle Society function scale score was 68.1; the mean Short Form-36 physical score was 41.8; and the mental score was 44.9. Pedabarographic results showed that the mean maximum force in the midfoot, forefoot, and toes (p = .001; p = .04; p = .002) and peak pressure in the midfoot, forefoot (p = .001; p = .007), and contact area of the midfoot and toes (p = .038; p = .004) were significantly increased in the injured foot. Radiologic findings showed hindfoot varus, forefoot adductus, and an increase in the medial arch. Even after appropriate anatomic realignment with open reduction and internal fixation of calcaneus fractures, residual differences in plantar pressures and radiographic measures are noted compared to uninjured foot.     

Fractures of the foot region of car drivers and passengers. Occurence, causes and long-term results

Summary During 1973 and 1989, 6,378 car accidents with 8,931 injured persons were evaluated in the area of Hannover. 3,267 car drivers and passengers sustained fractures overall and 148 (4,5 %) fractures of the foot. A major role in the ethiology of the foot fractures evolves from the deformation of the foot room. Driver and front seat passenger showed similar injuries. Among the 286 single fractures, the forefoot was affected most often (45 %), followed by ankle (38 %), midfoot (11 %) and hindfoot (6 %). 5 % were open fractures. The long term results were estimated upon the limitation of working ability caused by the foot injury in relation to the entire working ability. The evaluation concludes that the foot fractures especially in combination with other injuries were frequently not recognized within the primary examination and therefore underestimated. The long-term outcome leaded to a high degree of impairment due to foot fractures.      

Fixation of Lapidus Arthrodesis with a Plantar Interfragmentary Screw and Medial Locking Plate: A Report of 88 Cases

Lapidus arthrodesis is a powerful procedure that can be used to correct pathologic features within the forefoot or midfoot. Many different methods of fixation for this procedure have been reported. The use of plating constructs has been shown to provide increased stability compared with screw-only constructs. The technique we have described consists of a plantar to dorsal retrograde lag screw across the arthrodesis site, coupled with a low-profile medial locking plate. A total of 88 consecutive patients were treated with this modification of the Lapidus procedure by 2 surgeons and were retrospectively evaluated. All patients followed an early postoperative weightbearing protocol. Patient age, gender, follow-up duration, interval to weightbearing and radiographic fusion, preoperative and postoperative intermetatarsal angle, hardware removal, preoperative and postoperative American Orthopaedic Foot and Ankle Society midfoot scores, and adjunct procedures were analyzed. The mean follow-up period was 16.76 ± 5.9 (range 12 to 36) months, and all healed fusions demonstrated radiographic union at a mean of 51 ± 19.1 (range 40 to 89) days. The patients were treated with weightbearing starting a mean of 10.90 ± 4.1 (range 5 to 28) days postoperatively. Complications included 15 patients (17%) requiring hardware removal, 2 cases (2%) of hallux varus, 6 cases (7%) of radiographic recurrent hallux valgus, and 2 patients (2%) with first metatarsocuneiform nonunion. The results of the present study have demonstrated that plantar lag screw fixation with medial locking plate augmentation for Lapidus arthrodesis allows for early weightbearing with satisfactory outcomes, improved clinical and radiographic alignment, and improved American Orthopaedic Foot and Ankle Society scores.     

Midfoot and forefoot issues cavovarus foot: assessment and treatment issues

This chapter addresses the etiology and diagnosis of forefoot and midfoot cavovarus deformities, the relevant anatomy and biomechanics, and specific procedures for correction of the forefoot and midfoot. Associated hindfoot and ankle procedures will be referenced; however, their specifics will be reserved for other chapters.     

The Importance of Proper Shoe Gear and Safety Stirrups in the Prevention of Equestrian Foot Injuries

The aim of this study was to compile specific foot injuries occurring in pediatric patients that result from equestrian sports and to highlight the importance of wearing adequate riding boots to protect the feet. During a 12-year period, 258 children were admitted to Children's Hospital of Geneva for injuries resulting from horseback riding. Amongst these children, 8 sustained foot lesions that required hospital admission. Four children had compression-type fractures of the cuboid (nutcracker fracture of the cuboid) associated with other complex midfoot fractures, 2 had Lisfranc fracture dislocations, 1 had a fracture of the talus with associated intern malleolar fracture, and the last had a fracture of the 5 metatarsals with lateral displacement. All the noted lesions complied with the same traumatic mechanisms. The horse fell on the patient, and the child's foot, entrapped in the stirrup, was caught in between the animal and the ground. The forefoot was bent by indirect violence in abduction by the stirrup, which acted as a fulcrum. Serious foot injuries may occur in children during equestrian activities. These lesions may be very disabling. Therefore, it is important for doctors, instructors, and parents to promote the use of appropriate safety equipment, including strengthened riding boots and safety stirrups.     

Management of Complex Open Fracture Injuries of the Midfoot With External Fixation

Ten patients (11 feet) with severe, high-velocity, open injuries to the midfoot were treated with uniplanar external fixation. The mean patient age was 38 years. Five wounds measured >10 cm, and 3 had extensive degloving of the foot extending into the lower leg. All had grossly comminuted fractures of the tarsal and metatarsal bones: 9 patients had a fractured cuboid; 6 had a fractured navicular; 7 had a fractured cuneiform; and all had metatarsal fractures. Lisfranc joint dislocations were present in 7 feet, and intertarsal dislocations were seen in 3 cases. Six patients underwent split-thickness skin grafting, and 1 required a myocutaneous flap. The average duration of fixator use was 9 weeks (range, 6-15 weeks). Clinically, patients were evaluated 1 year after fixator removal for any residual pain in the foot, ability to stand on tiptoe, presence of a limp, deformity of an arch, and range of motion at the ankle, subtalar, and metatarsophalangeal joints. Each parameter was graded as good, fair, or poor. All patients had sensate plantigrade feet, with 2 patients who experienced pain on weight bearing, 5 who had difficulty standing comfortably on tiptoe, and 2 who limped because of pain. Three patients exhibited flatfoot deformity, whereas 4 had cavus deformity. All demonstrated stiffness at the midfoot and restriction of subtalar and forefoot motion, with 5 also having restricted ankle motion. Radiographically, all fractures were healed at the time of follow-up; 4 were malunited, with 1 demonstrating ankylosis across the tarsometatarsal joint. These results suggest that crush injuries to the midfoot often result in persistent morbidity despite early comprehensive management with external fixation.     

Möglichkeiten und Grenzen der konservativen Therapie: Fuß und Sprunggelenk

Injuries of the foot and ankle can often be conservatively treated; however, an appropriately adjusted treatment should be performed. In this article injuries of the Achilles tendon, ankle fractures, injuries of the syndesmosis, lateral ankle ligament ruptures as well as ongoing functional instability and midfoot fractures of the fifth metatarsal are discussed. A current overview of the conservative therapy is given and the limits of this treatment are demonstrated; however, an all-inclusive discourse is not possible within the scope of this article. Within an appropriate conservative treatment, the focus should, as far as possible, be on early functional treatment with appropriate weight bearing and early exercise treatment. Not only the therapist but also the patient should be aware of the often protracted convalescence time compared to operative treatment. The shorter treatment times for surgical interventions are contrasted by the disadvantage of surgical risks.     

An Alternative Technique for Fixation of Tongue-Type Calcaneal Fractures: The “Hurricane Strap”

Traditionally, tongue-type calcaneal fractures have been treated using screw fixation or tension band wiring. In this work, we aim to present a technique guide for an alternative approach to fixation of these fractures given the high potential for failure with traditional methods. Additionally, we present the results of 4 patients treated with this technique. A modified lateral extensile incision is made for application of a midfoot fusion plate that is pre-bent and fit to the calcaneus with 2 holes covering the superior surface of the calcaneus for bicortical interfragmentary purchase. Four screws are then placed orthogonally into the calcaneus through the plate. Typically, this allows for 2 screws to be placed in the superior fragment and 2 screws to be placed in the inferior fragment. All 4 patients went on to timely osseous union and were weightbearing in regular shoe gear at their last follow-up appointment. Average follow-up time was 16.5 (range 15 to 21) months. We believe that the “hurricane strap” provides a more mechanically sound construct than other methods. This construct may be especially useful in patients with osteoporotic bone where screws alone may not maintain adequate reduction or in neuropathic patients where noncompliance with weightbearing status may jeopardize maintenance of reduction.