Fractures Of The Midfoot PDF

Fractures of the Midfoot JARROD SMITH, DPM, FACFAS ASSISTANT PROFESSOR Learning Objectives u Demonstrate knowledge of the evaluation and treatment of midfoot fractures. u Demonstrate knowledge of the etiologies and mechanism of injury for midfoot fractures.  Midfoot Fracture Overview u T...

Fractures of the Midfoot JARROD SMITH, DPM, FACFAS ASSISTANT PROFESSOR Learning Objectives u Demonstrate knowledge of the evaluation and treatment of midfoot fractures. u Demonstrate knowledge of the etiologies and mechanism of injury for midfoot fractures.  Midfoot Fracture Overview u The midfoot includes bones between Chopart’s and Lisfranc joint lines: u Navicular – Keystone of the medial column u Cuneiforms u Cuboid – Keystone of the lateral column u Relatively rare – 5% of all foot fractures u Navicular fractures are the most common of the 3. u Fracture patterns are unusual u Usually occur in a complex with other injuries (osseous and ligamentous) u isolated injuries to midfoot bones are the exception and not the rule Schildhauer, Thomas A. Hoffman, Martin F. Chapter 67: Fractures and Dislocations of the Midfoot and Forefoot. Rockwood and Green’s Fractures in Adults, Ninth Edition. Philadelphia, PA: Wolter Kluwer, 2020.  Midfoot Fracture Overview Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Midfoot Fracture Overview Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Midfoot Fracture Overview Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Midfoot Fracture Overview u Initial evaluation of trauma patients u neurovascular exam to rule out compartment syndrome u dermatological exam to evaluate for open fractures and tented skin u musculoskeletal exam go to evaluate for strength deficits, range of motion, and instability u Can be difficult to diagnose by radiograph – up 30% are missed u Bony overlap of midfoot bones obscure visualization u CT scan is often required for traumatic injuries u MRIs are useful for ruling out stress fractures u Neglected or delayed diagnosis of midfoot fractures results in poor outcomes Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Midfoot Fracture Overview u Treatment u Depends on displacement, joint involvement, comminution, and column shortening u Non-displaced fractures u Generally conservative à NWB SLC for 6-8 weeks u Displaced fractures with large fragments u ORIF u Comminuted fractures u ORIF u External fixation u Bridge plating Schildhauer, Thomas A. Hoffman, Martin F. Chapter 67: Fractures and Dislocations of the Midfoot and Forefoot. Rockwood and Green’s Fractures in Adults, Ninth Edition. Philadelphia, PA: Wolter Kluwer, 2020.  Midfoot Fracture Overview u Treatment u Shortening of the medial or lateral column will require surgery (> 3 mm) u Navicular fracture à shortening of the medial column u Cuboid fracture à shortening of the lateral column Schildhauer, Thomas A. Hoffman, Martin F. Chapter 67: Fractures and Dislocations of the Midfoot and Forefoot. Rockwood and Green’s Fractures in Adults, Ninth Edition. Philadelphia, PA: Wolter Kluwer, 2020. General Mechanisms of Injury u Avulsion fractures u Foot moving in the opposite direction of tendon and/or ligament pull u Body fractures u Foot striking in a plantarflexed position u Direct trauma u Axial or rotational forces u Fracture/Dislocation u High energy injuries u Fall from height u MVA u Foot striking in a plantarflexed position u Often with an abduction or adduction rotation of the foot  Blood Supply of the Navicular u A large percentage of the navicular bone is covered in cartilage u the blood supply enters dorsally, plantarly, and from the tuberosity u the medial and lateral 1/3 possesses generally good vascularity u the central 1/3 is relatively avascular Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. Navicular Fractures u The most common midfoot fracture u 62% of all midfoot fractures u 0.37% of all fractures u Types u Tuberosity Fractures u Dorsal avulsion fractures u Body fractures u Stress fractures Watson-Jones Classification u Type 1 u Navicular tuberosity fractures u Type 2 u Dorsal lip avulsion fractures u Type 3 u Navicular body fractures u Type 4 u Navicular stress fracture Navicular Tuberosity Avulsion Fracture u 2nd most common at 24% of all navicular fractures u can be confused for an os naviculare/os tibiale externum u accessory ossicle can not be ruled out with bilateral films u accessory ossicles have a more rounded and smooth appearance u an accessory navicular can be symptomatic if the fibrous union is disrupted u mechanism of injury u eversion of the foot u pull of the posterior tibial tendon and spring ligament avulse the fragment Navicular Tuberosity Avulsion Fracture u physical exam u pain on palpation and edema medially at the navicular tuberosity u pain with active inversion of the foot u radiographs u best seen on lateral oblique view u fragment is usually nondisplaced or minimally displaced due to abundance of soft tissue attachments u treatment u generally conservative u 4-6 weeks in a weight-bearing cast u surgical indications u symptomatic nonunion following a course of immobilization (excision) u ORIF if fragment involves the talonavicular joint or the PT tendon is compromised  Dorsal Lip Avulsion Navicular Fracture u most common navicular fracture u 47% of all navicular fractures u mechanism of injury u plantar flexion with inversion u talonavicular ligament u plantar flexion with eversion u dorsal tibionavicular ligament (deltoid) Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Dorsal Lip Avulsion Navicular Fracture u physical exam u pain on palpation and edema dorsally at the talonavicular junction u radiographs u best seen on lateral view u treatment u generally conservative u 4-6 weeks in a weight-bearing cast u surgical indications u symptomatic fragment following a course of immobilization (excision) u ORIF if fragment involves > 20% of the articular surface Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Navicular Body Fracture u 3rd most common at 29% of all navicular fractures u types u nondisplaced u vertical u horizontal u displaced u Mechanism of injury u A fall with foot striking while plantarflexed Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Navicular Body Fracture - Nondisplaced u physical exam u pain on palpation with edema dorsally and medially at the navicular u pain with passive motion of the midfoot u radiographs u best seen on lateral and lateral oblique view u treatment u generally conservative u NWB SLC for 6-8 weeks Goldman, Flair D. Chapter 56: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Third Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.  Navicular Body Fracture - Displaced u classified by Sangeorzan et al. u Based on the orientation of the fracture line and ease of fracture reduction u Accuracy of reduction directly correlates to patient outcome Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. The journal of bone and joint surgery american volume. 1989;71(10):1504-1510.  Navicular Body Fracture - Displaced u Type 1- transverse fracture u dorsal fragment < 50% of the body u no disruption of the medial border u No angulation of the forefoot Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. The journal of bone and joint surgery american volume. 1989;71(10):1504-1510.  Navicular Body Fracture - Displaced u Type 2 - oblique fracture u most common u fracture line is dorsal lateral to plantar medial u main fragment is dorsal medial u Forefoot angulated medially Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. The journal of bone and joint surgery american volume. 1989;71(10):1504-1510.  Navicular Body Fracture - Displaced u Type 3 - central or lateral comminution u forefoot is laterally displaced u often seen with concomitant cuboid injury u Most difficult to reduce surgically Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. The journal of bone and joint surgery american volume. 1989;71(10):1504-1510. Navicular Stress Fractures u Accounts for up to 15% of pedal stress fractures in athletes u Usually occurs in the watershed (avascular) area u Is more common in track and field athletes as well as basketball players u Easily misdiagnosed u Midfoot sprain u Anterior tibial tendinitis u Posterior tibial tendinitis  Navicular Stress Fractures u Classified by Saxena u Type I – Fracture of the dorsal cortex u Type II – Fracture disseminates into the body u Type III – Fracture extends to a second cortex Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. The journal of foot and ankle surgery. 2000;39(2):96-103. Navicular Stress Fractures u Initial radiographs are often negative u Advanced imaging is usually required u CT u MRI u Bone Scan u Treatment of NSF remains controversial (conservative vs surgical) u Especially for athletes u NWB SLC has shown more favorable results than WB SLC Cuboid Fractures u Rarely an isolated injury u Often occur with medial column injuries u May be difficult to evaluate radiographically u 3 views (AP,MO, & Lat) are standard initially Cuboid Fractures u Rarely an isolated injury u Often occur with medial column injuries u May be difficult to evaluate radiographically u 3 views are critical u CT scan if your index of suspicion is high Cuboid Fractures u 3 types u Avulsion u Most common u Generally treated non-operatively u Can occur in an inversion ankle injury u Pull of the inferior calcaneocuboid ligament Cuboid Fractures u 3 types u Simple body fractures u Foot strikes in a plantarflexed position with axial or rotational forces u Direct trauma Cuboid Fractures u 3 types u Compression fractures u “Nutcracker fracture” u Severe abduction of the foot u Cuboid gets “cracked” between the 4th/5th met bases and the calcaneus Cuboid Fracture Treatment u Treatment goals u Restoration of joint surfaces u Restoration of lateral column length Cuboid Fracture Treatment u Avulsion fractures à conservative treatment (WB SLC for 6 weeks) u Non-displaced fractures à conservative treatment (WB SLC for 6 weeks) u Comminuted/crush injuries à surgical treatment u ORIF u External fixation u Bridge plating Cuneiform Fractures u Isolated cuneiform fractures are rare u More often a component of a complex injury u Midtarsal and tarsometatarsal dislocations u Fracture types u Avulsion à Medial cuneiform avulsion fx due to pull of AT tendon u Body à Axial or rotational forces and direct trauma u Fracture dislocation à Axial force applied to a plantarflexed foot u Lisfranc fracture/dislocation u Stress fractures Cuneiform Fractures u Treatment- u Based on displacement, comminution, and concomitant injury u Nondisplaced fractures u Conservative à WB SLC for 6-8 weeks u Displaced fractures u Closed reduction with percutaneous pinning u ORIF u Bridge plating u Primary arthrodesis  Recommended Reading & References u Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. The journal of bone and joint surgery american volume. 1989;71(10):1504-1510. u Motley, Travis A. Carpenter, Brian B. Chapter 105: Midfoot Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. u Schildhauer, Thomas A. Hoffman, Martin F. Chapter 67: Fractures and Dislocations of the Midfoot and Forefoot. Rockwood and Green’s Fractures in Adults, Ninth Edition. Philadelphia, PA: Wolter Kluwer, 2020. u Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CWC. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. British journal of sports medicine. 2015;49(6):370-376. u Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. The journal of foot and ankle surgery. 2000;39(2):96-103. Copyright Notice: u This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws.