INJURIES OF THE TARSO-METATARSAL JOINTS

Transcription

1 INJURIES OF THE TARSO-METATARSAL JOINTS Etiology, Classification and Results of Treatment D. W. WILSON, LONDON, ENGLAND Froni the Royal Free Hospital, London Dislocations of the tarso-nletatarsal joints are uncommon. Twenty-two injured feet of twenty patients treated at five centres have been reviewed and dissections of cadaveric feet have been done to study the possible mechanisms of injury. CLASSIFICATION Analysis of the clinical cases (Figs. 1 to 27) suggested that the injuries could be classified into five types (Table I). This classification was confirmed by experiment (Figs. 28 to 40). A review of sixty radiographs previously published showed that all but three could be classified within this scheme. Cases 1 5 and 17 in the present series are not typical, but a reasonable approximation could be found (Figs. 16 and 18). The fifth group of plantar-flexion injuries may escape detection unless the radiographs are studied closely (Figs. 26 and 27). Qu#{233}nu and Kflss (1909) pointed out that the medial cuneiform and navicular bones and the talus form parts of the same anatomical column as the first metatarsal bone. Displacement of the latter with all or part of the former (Fig. 18, Case 17) represents the same basic injury as dislocation of the first metatarsal bone alone. Similarly, on the lateral border of the foot, fractures of the cuboid bone (Figs. I, 5, 1 1 and 12; Cases 1, 5, 1 1 and 12 (right)) could be included with first or second degree supination and second degree pronation injuries. Fracture of the proximal metatarsal shafts could replace dislocation of its base (Figs. 9 and 10, Cases 9 and 10). Chip fractures of the metatarsal and tarsal bones were common (82 per cent). The distinction between pure dislocation and fracture-dislocation is not fundamental. First and second metatarsal diastasis, stressed by Qu#{233}nu and K#{252}ss(1909), is only a stage in both inversion and eversion injuries and is not important in classification, although it may have a bearing on injury to the dorsalis pedis vessels. EXPERIMENTS ON MECHANISM OF INJURY The anatomy of the region has been well described elsewhere (Collett, Hood and Andrews 1958: Jeffreys 1963; Wiley 1971). Experiments were done on eleven preserved feet, each cleared down to the intact tarsometatarsal region. Manual strains were applied to the forefoot while the hindfoot was held fixed. Mechanical force was used only in crushing experiments. Jeffreys (1963) has shown that inversion and eversion forces cause different dislocations. Inversion-Forced inversion of the forefoot ultimately caused dorsilateral dislocation of all five metatarsal bones, as Jeffreys (1963) described, but in two stages. Dorsilateral dislocation of the four lesser bones took place first, beginning laterally and progressing medially. Little displacement of the lateral three metatarsal bones was seen until after the second had given way (Figs. 28 and 29). With further force, dorsilateral dislocation of the first metatarsal was added (Fig. 30). Ei ersion-forcible eversion of the forefoot caused medial dislocation of the first metatarsal (Figs. 3 1 and 32) at first, but with further eversion, dorsilateral subluxation or fracture of the shafts of the lesser metatarsal bones occurred, starting laterally (Figs. 33 and 34). VOL. 54B, NO. 4, NOVFMRFR

2 678 D. W. VILSON Plantar-flexioiz-Forced plantar-flexion without rotation produced variable results. Three feet showed merely dorsal gaping of the tarso-metatarsal joints, which hinged on the plantar tissues without true dislocation. In one foot, initial rupture of the dorsal ligaments of the second and third joints was followed by a coronal fracture of the base of the first metatarsal bone (Figs. 35 and 36). Further strain displaced the bases of the second and third metatarsal bones FIC,. 1 FIG. 2 FIG. 3 FIG. 4 Case 1. Right. SI. Case 2. Right. Si. Case 3. Right. SI. Case4. Left FIG. 5 Case 5. Left. SI. FIG. 6 FIG. 7 FIG. S Case 6. Right Case 7. Left Case 8. Right Displacement Dorsilateral Medial Dorsal FIG. 9 Case 9. Right FIG. 10 FIG. 11 Case 10. Right Case 11. Left FIGS. 1 TO 11 Figure 1-Case 1. An 5.1 injury to the right foot which was trapped under a girder and the patient fell backwards. Figure 2-Case 2. An S. 1 injury to the right foot in a road traffic accident (motor-cycle) details unknown. Figure 3-Case 3. An 5.1 injury to the right foot in a road traffic accident to a front seat passenger, car. The foot was in plantar-flexion on sloping floor. Figure 4-Case 4. An 5.1 injury to the left foot caused by falling at tennis and sitting on the inverted foot. Figure 5-Case 5. An 5.1 injury to the left foot in a road traffic accident (motor-cycle), details unknown. Figure 6-Case 6. An 5.2 injury to the right foot from falling downstairs. Figure 7-Case 7. An S.2 injury to the left foot in a road traffic accident (motor-cycle), details unknown. Figure 8-Case 8. An 5.2. injury to the right foot in a road traffic accident to a front seat passenger, car. The foot was in plantar-flexion on sloping floor with pressure on the toes. Figure 9-Case 9. An 5.2 injury to the right foot to a pedestrian in a road traffic accident. Figure 10-Case 10. An 5.2 injury to the right foot in a road traffic accident on a motor-cycle, details unknown. Figure I I -Case I I. An 5.2 injury to the left foot in a road traffic accident to a front seat passenger, car. dorsally followed by the lateral two (Fig. 37). There was no lateral shift of the bones. The distal fragment of the first metatarsal bone trapped the dissected dorsalis pedis artery on the cuneiform. This was the only dissection showing any obvious vascular involvement. With another foot, the first lesion was a dorsal subluxation of the second metatarsal bone alone (Fig. 38). Further force then displaced the remainder (Figs. 39 and 40). Chip fractures from the tarsal and metatarsal bones were invariable in all the dissections. TIlE JOURNAL OF BONE AND JOINT SURGERY

3 INJURIES OF THE TARSO-METATARSAL JOINTS 679 Dorsfiexion-Attempts to produce dislocation by strong dorsifiexion of the forefoot were unsuccessful. Crushing force-two feet were crushed in a vice, with dorsi-plantar compression between a board beneath the sole (representing the ground) and a jaw of the vice on the dorsum of the FIG. 12 FIG. 13 Case 12. Right Case 12. Left. P.1. FIG. 14 Case 13. Left. P.1. FIG. 15 Case 14. Right. P.1. I FIG. 16 Case 15. Right. P.1, mixed. IFIG. 17 Case 16. Left. P.2. UFIG. 18 Case 17. Right. P.2, atypical. IFIG. 19 Case 18. Left. PF. Displacement [_IiII Dorsilateral Medial Dorsal FIG. 20 Case 19. Right. PF. FIG. 21 Case 19. Left. PF. FIGS. 12 TO 22 FIG. 22 Case 20. Left. PF. Figures 12 and 13-Case 12. An S.2 injury to the right foot (Fig. 12) and a P.1 injury to the left foot (Fig. 13) caused by a road traffic accident to the driver but the details were not known. Figure 14- Case 13. A P.1 injury to the left foot when a ladder slipped and the foot caught in rung and the patient fell backwards. Figure 15-Case 14. A P.1 injury to the right foot in falling downstairs with the foot in plantar-flexion and eversion. Figure 16-Case 15. A P.! injury to the right foot caused by the foot slipping off a stool in plantar-flexion. Figure 17-Case 16. A P.2 injury to the left foot in a road traffic accident on a bicycle, details unknown. Figure 18-Case 17. A P.2 injury to the right foot which was atypical and was caused by a road traffic accident with a motor-cycle. The foot was trapped by the wing of the car. Figure 19-Case I 8. A plantar-flexion injury to the left foot caused by dropping a steel plate on to the foot. Figures 20 and 21-Case 19. A plantar-flexion injury to the right foot (Fig. 20) and left foot (Fig. 21) caused by a road traffic accident, details unknown. Figure 22-Case 20. A plantar-flexion injury to the left foot caused by the child putting a foot into a hole for a post and falling backwards. tarsus. Bones were splintered, joints sprung open and the arch flattened completely, but no true dislocation was seen. When released the bones returned to their original positions. Side-to-side compression of another specimen in the vice produced multiple fractures but again no dislocation, and in particular no dorsal extrusion of the second metatarsal base in the way that a fruit pip is squeezed between the fingers ( m#{233}canisme du noyau de cerise, Qu#{233}nuand Kflss 1909a). VOL. 54 B, NO. 4, NOVEMBER 1972 H

4 680 D. W. WILSON DISCUSSION ON ETIOLOGY In this series, road accidents accounted for 64 per cent of the injuries. Clear histories obtained from nine patients suggested that the usual mechanism was one of forced plantarflexion and rotation. Occasionally, forcible plantar-flexion alone may have been responsible (Fig. 22, Case 20). FIG. 23 FIG. 24 Figure 23-Case 13. A P.1 injury to the left foot. The oblique radiograph shows rotation of the first metatarsal bone when it is compared with the undisplaced lesser metatarsal bones. Figure 24- Case 16. A P.2 injury to the left foot is shown in an antero-posterior radiograph. Most authors have agreed that the foot must be in plantar-fiexion at the time of injury (Qu#{233}nuand Kflss l909a, Aitken and Poulson 1963, Wiley 1971). In dorsiflexion, strains fall on the ankle (Lauge-Hansen 1950). Forced plantar-flexion can occur in three ways: by longitudinal compression (Ashhurst 1926, Aitken and Poulson 1963, Wiley 1971), by backward THE JOURNAL OF BONE AND JOINT SURGERY

5 INJURIES OF THE TARSO-METATARSAL JOINTS 681 TABLE CLASSIFICATION AND INCIDENCE OF EACH TYPE I Type Typical displacement Incidence Feet Per cent Forefoot eversion (pronation) First stage L Second stage - P. 1 P.2 Medial dislocation of first metatarsal bone alone 4 18 Medial dislocation of first metatarsal bone and dorsilateral dislocation of the four lesser 2 9 metatarsal bones First sta e Forefoot inversion g (supination),second stage Dorsilateral dislocation of up to four lesser S. I metatarsal bones Dorsilateral dislocation ofall five metatarsal bones 7 32 Plantar-flexion alone.. PF Total... Dorsal subluxation of base of second metatarsal and/or coronal fracture-dislocation of base of 4 18 first metatarsal bone falls with the forefoot entrapped and by falls on to the point of the toes. In simulating falls down stairs and from capsizing stools, when the plantar-fiexed leading foot met the ground, it often rolled on to the dorsum of the toes (Chavasse 1884), increasing the plantar-flexion still more. Plantar-flexion strains probably cause the isolated subluxation of the second metatarsal (Novotny 1953) seen thrice in this series (Figs. 19, 20 and 22; Cases 18, 19 (right) and 20). FIG. 28 FIG. 29 FIG. 30 Diagrams showing an experimental foot subjected to forcible forefoot inversion (supination). Rupture of the dorsal ligaments of the cubo-metatarsal joints has occurred (1 in Fig. 28), followed by subluxation of the fifth metatarsal bone, fourth metatarsal bone and the third metatarsal bone (2 in Fig. 28). There is then rupture of the dorsal ligament of the intermediate cuneiform metatarsal joint (3 in Fig. 29) and a dorsilateral dislocation of all the lesser metatarsal bones (4 in Fig. 29). Finally there is dorsilateral dislocation of the first metatarsal bone with its base rotated away from the medial cuneiform (5 in Fig. 30). In car accidents people in front seats have their feet fixed in plantar-flexion on the sloping floor (Aitken and Poulson 1963, Wiley 1971) and are vulnerable so far as these injuries are concerned. Pure abduction strain has been incriminated (Collett et a!. 1958, Wiley 1971), but this cannot account for all the patterns of injury found, particularly medial dislocation of the first metatarsal bone (seen in pronation injuries), or sparing of this bone (as in first degree supination injuries). In contrast, quite minor rotational force easily produces all the typical patterns ofdislocation seen clinically (Easton 1938, Gissane 1951, Novotny 1953, del Sel 1955, Jeifreys 1963). VOL. 54 B, NO. 4, NOVEMBER 1972

6 682 D. W. WILSON SECOND METATARSAL TORN INTEROSSEOUS STRUCTURES. FIG. 31 FIG. 32 FIG. 33 FIG. 34 Diagrams showing an experimental foot subjected to forcible forefoot eversion (pronation). Figure 31 is a diagram showing how the rotatory medial displacement of the first metatarsal bone occurs. The sequence of the joint injuries is first a medial dislocation of the first metatarsal bone (1 in Fig. 32) then subluxation of the fifth metatarsal bone and fourth metatarsal bone (2 in Fig. 33) and finally fracture of proximal shafts of the third metatarsal bone and the second metatarsal bone (3 in Fig. 34). Dorsilateral dislocation of the fifth metatarsal bone and the fourth metatarsal bone was now possible. ck FIG. 35 FIG. 36 FIG. 37 Diagrams showing an experimental foot subjected to forcible plantar-flexion. There has been rupture of the dorsal ligaments of the intermediate and lateral cuneiform metatarsal joints (1 in Fig. 35) followed by a coronal fracture of the first metatarsal bone (2 in Fig. 35). The lateral view shows the coronal slice fracture of the base of the first metatarsal bone, extending into the joint, with dorsal displacement of the shaft fragment (2 in Fig. 36). There was later dorsal subluxation of the second metatarsal bone and the third metatarsal bone and of the other lesser metatarsal bones (3 and 4 in Fig. 37). FIG. 38 FIG. 39 FIG. 40 Diagrams showing an experimental foot that was subjected to forcible plantar-flexion. There was dorsal subluxation of the second metatarsal bone (1 in Fig. 38), followed by dorsal subluxation of the medial cuneiform, the first metatarsal bone and the third metatarsal bone (2 in Fig. 39) and later by a fracture of the proximal shaft of the fifth metatarsal bone and dorsal subluxation of the fourth metatarsal bone (3 and 4 in Fig. 40). THE JOURNAL OF BONE AND JOINT SURGERY

7 INJURIES OF THE TARSO-METATARSAL JOINTS 683 FIG. 42 FIG. 43 Figures 41 and 42-Case 8. An oblique radiograph showing the position after open reduction and fixation with Kirschner wires (Fig. 41). Another oblique radiograph, sixteen months after injury, shows degenerative changes in tarso-metatarsal joints (Fig. 42). Figure 43-Radiograph of a foot that had been trapped under the wheel of a lorry. Pure crushing has occurred, the patient had remained upright throughout. There was extensive softtissue injury, a compound fracture of the second metatarsal bone, fractures of intermediate cuneiform and navicular bones and gaping of the joint between the medial and intermediate cuneiform bones. In general, the skeletal shape has been well maintained and there was no true dislocation. in Case 12 of this series (Figs. 12 and 13) the different dislocation in each foot suggests that the trunk was thrown to one side, rotating the feet in opposite directions. Pure crushing was seen in only one instance (Fig. 19, Case 18). It is suggested that, to sustain dislocation in the crushed foot, some element of rotation or hyperplantar-fiexion is also needed. This is added only if the patient s body falls to the ground (Fig. 43). TREATMENT The definitive methods of treatment adopted and the results are shown in Table II. The numbers were small and full details were not available for each factor considered, but some conclusions could be drawn. Qualitv of reduction-the quality of the reduction was assessed from radiographs of twenty feet immediately after definitive treatment. Two had had no significant initial displacement (Cases 18 and 19 (left)) and were excluded from analysis. Four of the eighteen feet remaining had been subjected to operation (Fig. 41), and in three reduction was anatomical or nearly so. Of fourteen feet treated conservatively, in only one was anatomical reduction obtained : in seven there was residual displacement of five millimetres or more. Pain-If residual pain was complained of, it was assessed as slight or moderate. No patient complained of severe pain. Of four feet treated by operation, three were painless and the other had only slight pain. Of fifteen feet treated conservatively, only two were free from pain and five caused moderate pain. Of six feet with anatomical reduction, four caused no pain but two gave slight pain. Of six feet with marked residual displacement (5 millimetres or more), five caused moderate pain. VOL. 54 B, NO. 4, NOVEMBER 1972

8 684 D. W. WILSON TABLE II RESULTS OF TREATMENT Final treatment adopted Plaster Manipula-. None cast tion and only plaster Softtissue closure Open reduction Metatarsals Metatarsais Totals not fixed fixed internally Nwnber of feet reviewed Radiological reduction Anatomical or < 2 millimetres Residual to 4 millimetres displacement 2f I I to 10 millimetres 2 : Over 10 millimetres Pain None it 2 5 Slight Moderate Limp None....., Slight Marked..... Deformity None S 2 I 1 6 Slight Valgus.. Cavus.. 3 I 4 1 I Marked Vaigus Cavus.. I Bony bosses I Movement Foot Over half.. 4 Halfor less. 2 2 I Metatarso- phalangeal Over half.. I joint Toes Half or less I 10 Totals * The radiographs of two feet after operation were not available for review. t Case 19 (left) had no displacement. Case I 8 had less then 2 millimetres displacement which was left unreduced. S Case 14 had a pre-existing bilateral pes cavus which remained unchanged. THE JOURNAL OF BONE AND JOINT SURGERY

9 INJURIES OF THE TARSO-METATARSAL JOINTS 685 Deformity-Deformity was graded into slight (six feet) or marked (four feet). Valgus deformity, seen in six feet, was associated with the supination (four feet) or plantar-flexion (two feet) types of injury. Cavus deformity (four feet) followed pronation type injuries in two feet. No foot treated by operation was more than slightly misshapen. All four feet with marked deformity had been managed conservatively, two with manipulation. However, the remaining eight feet in this group were of normal shape or had only slight deformity. Of five feet with poor reduction (5 millimetres or more displacement), four had marked deformity. With no more than 4 millimetres of residual displacement, a normal shape resulted in four feet, or only slight deformity in five feet. Three of the four patients with badly misshapen feet had had to change their occupations and to giveup active hobbies and sports because oftheir feet. Thirteen of fifteen feet seen personally showed bony bosses around joints, representing either residual bony displacements or osteophytes. Stiffness-Stiffness was found in all but two feet reviewed. Of thirteen feet, six had half or less of the normal tarsal movement. The quality of reduction influenced this stiffness but the treatment by which it was obtained did not. Of five feet with more than 5 millimetres residual displacement, four had less than half the normal tarsal movement, whereas of seven feet with no more than 4 millimetres of displacement only two were as stiff. Also, stiffness of the metatarso-phalangeal joints of the toes often occurred, eight of thirteen feet having half or less of the normal range of movement in the great toe. Again, this was related to quality of reduction. Among five feet with 5 millimetres or more displacement four had half or less of normal movement, while of six feet with better reduction than this, only two were as stiff. Limp-Limp was noted in twelve of sixteen patients. There was no correlation with either pain or stiffness. No patient used a stick. Degenerative arthritis-degenerative joint changes were always present in radiographs taken some time after the accident. Even cases with anatomical reduction by operation were not exempt (Fig. 42). Conclusions-In general, the least active conservative treatment gave poor reduction and consequent pain. Successful reduction by manipulation or operation with anatomical or good position on radiographs, gave more comfortable, better shaped feet. This agrees with the results of Granberry and Lipscomb (1962). If open reduction is undertaken, transfixion of the replaced joints with Kirschner wires (del Sel 1955, English 1964) is simple and effective (Fig. 41). The wires are removed after six weeks, and before the patient bears weight on the foot. Bony bosses, minor joint stiffness and late degenerative changes were almost universal. VASCULAR COMPLICATIONS Gissane (1951) emphasised the risk of arterial damage in these injuries when the space between the first and second metatarsal bones was involved. Three patients in this series had impaired circulation to the toes. The patient in Case 1, with a compound first degree supination injury, suffered gangrene of the little toe, probably from severe local trauma to the lateral aspect of the foot. At review the dorsalis pedis pulsation was preserved. In Cases 17 (second degree pronation) and 20 (plantar-flexion), toe ischaemia was followed by spontaneous recovery but the first intermetatarsal space had been deranged and the dorsalis pedis pulse was permanently lost. SUMMARY I. Twenty-two feet injured at the tarso-metatarsal level are reviewed. 2. Experiments with eleven cadaveric feet are reported. 3. The injuries are caused by forced plantar-flexion combined with rotation in most cases. Crushing of the foot alone often does not produce dislocation. 4. A classification is suggested. 5. The results of various treatments in this small series are presented. It is concluded that anatomical reduction is important, achieved if necessary by operation and internal fixation. VOL. 54 B, NO. 4, NOVEMBER 1972

10 686 D. W. WILSON I am indebted to the following surgeons for permission to quote their cases and for their considerable help and encouragement : Mr A. Benjamin and Mr K. I. Nissen (Watford General Hospital), Mr A. S. Dawson (Queen Elizabeth II Hospital, Welwyn), Mr C. Gray and Mr J. C. R. Hindenach (Royal Free Group of Hospitals, London), Mr W. Herscheland Mr R. H. Maudsley(Heatherwood Hospital, Ascot), Mr D. Walker and Mr F. G. Ward (Ashford Hospital, Middlesex). I am grateful to Professor R. Bowden (Royal Free Hospital Medical School) for access to the material for dissection, and to the Department of Clinical Photography (Royal Free Hospital) for the illustrations. REFERENCES AITKEN, A. P., and POULSON, D. (1963) : Dislocations of the Tarsometatarsal Joint. Journal of Bone and Joint Surgery, 45-A, 246. ASHHURST, A. P. C. (1926): Divergent Dislocation of the Metatarsus. Annals of Surgery, 83, 132. CHAVASSE, M. (1884): Contribution a l #{233}tudedes luxations tarso-m#{233}tatarsiennes. Revue de chirurgie, 4, 542. COLLETF, H. S., HOOD, T. K., and ANDREWS, R. E. (1958): Tarsometatarsal Fracture Dislocations. Surgery, Gynecology and Obstetrics, 106, 623. EASTON, E. R. (1938): Two Rare Dislocations of the Metatarsals at Lisfranc s Joint. Journal ofbone and Joint Surgery, 20, ENGLISH, T. A. (1964): Dislocations of the Metatarsal Bone and Adjacent Toe. Journal of Bone and Joint Surgery, 46-B, 700. GISSANE, W. (1951): A Dangerous Type of Fracture of the Foot. JournalofBone andjoint Surgery, 33-B, 535. GRANBERRY, W. M., and LIPSCOMB, P. R. (1962): Dislocation of the Tarsometatarsal Joints. Surgery, Gynecology and Obstetrics, 114, 467. JEFFREYS, T. E. (1963): Lisfranc s Fracture-dislocation. Journal of Bone and Joint Surgery, 45-B, 546. LAUGE-HANSEN, N. (1950): Fractures of the Ankle II. Combined Experimental-Surgical and Experimental- Roentgenologic Investigations. Archives of Surgery, 60, 957. NovomY, H. (1953) : Subluxatio Tarso-metatarsea. Acta chfrurgica Scandinavica, 105, 467. QUENU, E., and KOss, G. (1909a): Etude sur les luxations du m#{233}tatarse (Luxations mdtatarso-tarsiennes). Revue de chirurgie, 39, 1, 281, 720, QUNU, E., and KUss, G. (1909b): Etude sur les luxations du m#{233}tatarse (Luxations m#{233}tatarso-tarsiennes). Revue de chirurgie, 40, 104. SEL, J. M. del (1955): The Surgical Treatment of Tarso-metatarsal Fracture-dislocations. Journal ofbone and Joint Surgery, 37-B, 203. WILEY, J. J. (1971): The Mechanism of Tarso-metatarsal Joint Injuries. Journal of Bone and Joint Surgery, 53-B, 474. THE JOURNAL OF BONE AND JOINT SURGERY