Peggers Super Summaries: Foot Injuries

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1 Lisfranc Injury ANATOMY Roman arch with recessed 2 nd MT base AP medial side of intermediate cuneiform to 2 nd MT base Oblique medial side of lateral cuneiform with 3 rd MT base and 4 th with medial boarder of cuboid N/V bundle medial to EH Brevis MECHANISM Low force - Axial force on plantarflexed ankle High energy SUBTLE SIGNS MT neck fracture Nutcracker cuboid - # cuboid Fleck sign at base of 2 nd MT Mx Stable if weight bearing xrays normal can use walking boot Unstable 4mm cannulated screws o 1 st surgical fix 1 st MT to medial cuneiform distal to proximal o 2 nd fix 2 nd Mt to intermediate cuneiform o Then medial cuneiform to base of 2 nd MT o K wires to lesser MT o Rehab 6/52 NWB 6/52 weight bearing cast Arch support 1 year +/- lifelong 18/12 rehab ANKLE FRACTURE Aklas % of ankle fractures have OCD lesion o Arthroscope if not getting better ongoing pain could be caused by OCD Coalition Tendinopathy Instability Occult # Ankle Injuries SOFT TISSUE LIGAMENT INJURY Deltoid ligament o Ligaments Superficial

2 Deep ligament o Clinically Pain and giving way Unable to change directions Pain descending down stairs Lateral ligaments o Weight bearing x rays o Or stress views in theatre for laxity o Fix with brostrom modified gould technique + use valgus osteotomy of calcaneum if there is varus SYNDESMOSIS Posterior ligament stronger than AITFL Is 2-4 cm proximal to joint Mx o No diastasis cast for 8 weeks o Instability 2 screws +/- repair medial side STRESS FRACTURE McCabe et al 2012 vit D and calcium reduce stress fractures by 20% Sesamoid stress fracture use offloading orthotic or fix if not bipartite Lateral ankle instability COMMON CAUSES OF LATERAL LIGAMENT RECON FAILURE Varus heel or under pronator o Using coleman block test assess if varus correctable o Correct with lateralising calcaneum +/- dorsiflexing 1 st MT Generalised ligament laxity or Beighton score IMAGING Stress radiographs o Assess talar tilt vs subtalar movement o Calcaneal fibular ligament injury can cause both Subtalar and talar joint instability MRI o Assc OCD or tendinopathy o Calcaneofibular ligament injury o Peroneal injury ARTHROSCOPY Tibial spurs

3 OCD Unexplained pain SURGICAL RECONSTRUCITON Olliers cosmetic incision but cannot explore peroneals Longitudinal o Browstrom +/- half of peroneal brevis to reinforce repair o Gould augment retinaculum repair o Free tendon grafts Autograft hamstring allograft Jones fracture ZONES 1 insertion of peroneal brevis 2 watershed between tuberosity and 4/5 th articulation 3 distal to 4/5 th MT articulation Mx 1 usually heals 3 immobilisation Malleyt et good outcome 2 o non athletes NWB cast 6-8 weeks if no callus then electrotherapy o Athletes fix to decrease time away from sport NON UNIONS Screw High energy shockwave FIXATIONS Foot flat on bed II underneath Start dorsal and medial to tuberosity above peroneal brevis is the safe zone to avoid sural nerve Partially threaded cannulated screw or Herbert large Hind foot Injuries:

4 CALCANEUM Occur due to either axial loading or twisting injuries Anatomy o Anterior half contains 3 facets Posterior facet largest most weight bearing Middle facet sustentaculum tali Anterior facet o Sinus tarsi found between middle and posterior facets Swelling and widening of the heel / bruising extending to the heel is suggestive Associated with B/L calcaneal fractures 10% lumbar spine 10% lower limb fractures 25% Radiographic evaluation Bohlers angle degrees & Gissane degrees Fracture pattern o Intra-articular Primary fracture line most of these include the posterior facet Secondary fracture line results in continued force post primary fracture. Includes tongue fracture and joint depression fractures o Extra-articular include Anterior process # - calcaneal cuboid compression Tuberosity # from Achilles avulsion Medial process fractures valgus injury Sustentacular fractures loading and inversion TALUS Fall from height or RTA or hyperdorsiflexion injury Swelling and tenderness around hind foot with arch bruising / painful ROM Retrograde blood supply to dome If revascularization is occurring the talus undergoes subchondral resorption at 6-8 weeks HAWKINS Sign Fractures can include the following o Lateral process o Posterior process extends into subtalar joint o Talar head o Talar body o Talar neck Hawkins classification Type 1 non displaced 10% AVN Type 2 displaced with subtalar subluxation / dislocation 30% AVN Type 3 Displaced with dislocation from subtalar and ankle joints 90% Type 4 3 joint subluxation to also include talar navicular dislocation CHOPARTS JOINT Midtarsal joint involving o Talonavicular o Calcaneaocuboid

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