Chapter 25: TraumaMedical Management and Assessment of the

Polytrauma PatientAssessment of Lower Extremity InjuryGeneral Evaluation and Treatment of FracturesCalcaneal FracturesTalar FracturesOsteochondral FracturesNavicular FracturesCuboid FracturesCuneiform FracturesFifth Metatarsal Base FracturesMetatarsal Fractures (1st, 2nd, 3rd & 4th)Tarsometatarsal Joint Dislocations/FracturesSubtalar Joint DislocationsAnkle FracturesAnkle Inversion SprainDeltoid Ligament Ruptures Compartment SyndromeOpen Fracture Classification System and TreatmentSoft Tissue InjuriesCrush, Gunshot, and Lawnmower InjuriesPuncture WoundsEpiphyseal Plate Injuries (also see chapter 19, Pediatrics)Digital Fractures and Dislocations 1st MPTJ Trauma Nail Bed Trauma Toe Tip Injuries With Tissue Loss Dog and Cat Bites

TRAUMAMedical Management and General Assessment ofthe Trauma Patient1. 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 hemorrhagec. Inspect patient for skin color, alertness, chest wall motion, and extremity motiond. 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

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)

h. If patient still hypotensive insert arterial line to monitor BP and blood gasesi. Initiate EKG monitoringj. Assess neurologic status by Glasgow coma scalei. Check pupillary response, extremity posturing, and response to commandsii. Evaluate motor function of all extremities and trunkiii. If sensory and/or motor deficit, establish spinal cord level of functional changesk. 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

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

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

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 fracturesg. Complete neurologic examinationh. Tetanus prophylaxisi. Culture and sensitivity of open woundsj. 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 Injury1. Examination:a. Rapid neurovascular assessment

b. Quantity and quality of pulsesc. Observe motor functiond. Inspect for lacerations, swelling, deformities e. Joints palpated

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 waterb. 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 Fractures1. Determine type of fracture: a. Classification of fractures:i. Transverseii. Obliqueiii. Spiral

NOTE* Signs of ischemia are pain, pallor, paresthesias, paralysis, pulselessness. You have 6 hours to reverse before permanent pathological changes occur

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

iv. Comminutedb. Stable or unstable:i. How much bone to bone contact is there?ii. Are the fragments well aligned? iii. Is the area subject to movement?iv. How extensive is the soft tissue involvement?v. How is the blood supply to the fractured segment? vi. What kind of bone is involved in the fracture?c. Open or closedd. Intraarticular or extraarticulard. Cortical or cancellous bone involvement

e. Description of a fracture based upon the 4 basic relationships (described by the mnemonic LARD):i. Length and locationii. Angulationiii. Rotationiv. Displacement

2. Treatment of fractures: After determining the location and evaluatingthe patient's physiological status, a treatment regimen is tailored to thepatient's needs:a. Rest, Ice, Immobilization, Compression, Elevationb. Closed reduction (with or without internal fixation). The mechanisms ofclosed reduction are:i. Step 1- Increase the deformityii. Step 2- Distract the fragmentsiii. Step 3- Reverse the mechanism of injuryc. Open reduction (with or without internal fixation) d. Excision of fracture fragments e. Amputation

Calcaneal FracturesA disabling injury of the foot. There are a number of associated injuries when dealing with a calcaneal fracture including: compression fracture of the lumbar vertebrae, laceration of the kidney-renal damage, fractures of the lower extremity, and compartment syndrome 1. Anatomical considerations:a. The largest tarsal bone that has a thin cortical shell enclosing cancellous

NOTE* Characteristics of cortical and cancellous boneCortical Cancellous

Osteogenic properties poor goodFractures surfaces small largeSoft tissue support poor (few) goodVascularization poor goodInherent stability poor good

bone that contains traction trabeculae radiating from the inferior cortex and pressure lamellae converging to support the posterior and anterior facets.b. The calcaneus articulates with the talus through 3 facets, the largest being the posteriorc. 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.d. The lateral end of the tarsal canal gives attachment to the bifurcate ligament, the EDB, and the inferior extensor retinaculum.e. 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. 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. Radiological Examination a. Plain film x-rays

i. A-P viewii. Lateral viewiii. Anthensen's view (demonstrates medial and posterior facets of the STJ)iv. Isherwood views: Oblique lateral (anterior process and calcaneocuboid) Medial oblique axial (medial and posterior facet) Lateral oblique axial (posterior facet) v. Broden's projections Broden 1 (shows the posterior facet from anterior) Broden 2 (shows the sinus tarsi to posterior) b. Tomographyc. CT scanning (The Gold Standard)

3. Classification: Due to the fact that two types of fractures exist (intra-articular 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, replacing Rowe 4 8 5) a. Rowe:i. Type 1a: Fracture of the tuberosityii. Type 1b: Fracture of the sustentaculum taliiii. Type 1c: Fracture of the anterior process (most common; femalepatients predominate, mostly related to wearing high heeled shoes) iv. Type 2a: Beak fracturev. Type 2b: Avulsion fracture involving the tendo Achilles insertion vi. Type 3: Oblique body fracture not involving the STJ vii. Type 4: Body fracture involving the STJ viii. Type 5: Joint depression fracture with comminution

NOTE* Evaluating integrity of the bone plus Boehler's angle and the Critical angle of Gissane is essential in the diagnosis

b. Essex-Lopresti:i. Fractures not involving the STJ: Tuberosity fractures Beak type Avulsion medial border -Vertical Horizontalii. Fractures involving the calcaneal-cuboid joint: Parrot-nose type Variousiii. Fractures involving the STJ: Without displacement Tongue-type with displacement Centro-lateral depression of the joint Sustentaculum tali fracture alone Comminuted

c. Sanders: A new classification that utilizes CT scanning rather than plain radiographs for its identification. This is the first system to have a prognostic valuei. Type 1: nondisplacedii. Type 2: two part posterior facet fracture(a) Fracture through the lateral column (b) Fracture through the central column(c) Fracture through the medial columniii. 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. Type 4: Four part posterior facet fracture

4. Mechanism of injuries:a. Torque injuries (extra-articular fractures)i. Anterior process fxii. Avulsion fxiii. Sustentacular fx

b. Direct impaction (extra-articular fractures) i. Tuberosity fxii. Beak fxc. Falls from a height (intra-articular fractures)

NOTE* The primary fracture line is vertical from the vertex of the critical angle of Gissane to the plantar aspect. The secondary fracture line is determined by the direction of the force

d. Concussive force from below (intra-articular fractures)

5. Clinical Diagnosis of Calcaneal Fractures: a. Anterior process fractures:i. Swelling- well defined 3-4 cm. anterior to the lateral malleolus ii. Inversion and adduction increase pain

b. Beak and avulsion fractures:i. "Pop" sound heard/felt on the heel with sudden pain ii. Pes planus antalgic gaitiii. Weakness of plantarflexioniv. Edema, ecchymosis, bullous lesions (Mondor's sign) c. Fractures of the medial and lateral process: i. Heel thickens, edema, and ecchymosisii. ROM of ankle, STJ, and MTJ within normal limits d. Fracture of the body no STJ involvementi. Inability to bear weightii. Edema/ecchymosisiii. Generalized pain around the heeliv. Pain with ROM of ankle and STJe. Fracture of sustentaculum talii. Pain and edema on the medial aspect of the foot 1 inch below the medial malleolusii. Pain inferior to medial malleolus on dorsiflexion (FHL) iii. STJ ROM decreased and painfuliv. Ankle joint ROM WNLf. Tongue depression fracturesi. Rapid edema and severe pain and inability to bear weight ii. Severe bleeding under fasciaiii. Discoloration of the heel extending to the calf iv. Blister formationv. Flattened archvi. Decreased plantarflexion (Hoffa's sign)vii. Widened heelviii. R/O compression fracture of lumbar vertebrae and ankle (10% occurrence)

6. Treatment:a. Anterior process fractures:i. Small fragment fractures Soft cast NWB for 2-4 weeks (early mobilization important)ii. Large displacement fragment RIF or excision (it is recommended to wait 1 year before excision)

b. Beak or avulsion fractures:i. Beak fractures

NOTE* Must R/O 5th metatarsal base fractures

NOTE* Treatment for significant calcaneal fractures has traditionally been conservative (either closed reduction or posterior percutaneous pin fixation). However, 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, significant malalignment in varus or valgus, and lateral impingement syndromes). If the talus was left impacted into the posterior facet region, anterior ankle arthritis developed. Because of this, new techniques have been advocated.Open Reduction Technique:The lateral approach is used most for the primary incision. The medial approach is used when needed for more accurate reduction and rigid stabilization, or when CT scan demonstrates that most of the pathology lies medial in the fracture. A wide lateral flap is made incorporating the peroneal tendons and sural nerve, down to the subperiosteal layer.Timing is important to give a satisfactory result. Some advocate waiting 4-7 days to allow the swelling to resolve, 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. Either 3.5 mm. cortical or 4.0 mm. cancellous screws can be used to fix the reduced posterior facet to the sustentacular fragment b. Neutralize the entire calcaneus with 3.5 mm. reconstruction plates, flattened 1/3 tubular plates (possible in combination), or cervical plates (plates are recommended for neutralizing the interfragmental screw repair and for holding the lateral wall

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 castii. 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 weeksc. Fractures of the medial and lateral process:i. For nondisplaced treat with compression dressing/ice/elevation NWB. After edema subsides, follow with well molded BK cast for 4 weeksiii. For displaced fragment closed reduction followed by BK NWB cast for 6 weeks

d. Fracture of the body not involving the STJ:i. For non displaced use compression dressing/ice/elevation with ROM exercises immediately (NWB 4-6 weeks)ii. If displaced, closed reduction with BK NWB cast 6-8 weeks (Steinmann pin can be used with proximal displacement)

e. Fracture of the sustentaculum tali:i. Compression dressing/ice/elevationii. ROM excercises immediately for FHLiii. BK cast with progressive weightbearing iv. Firm shoe with orthosesv. If displaced closed reduction followed by BK cast 4 weeks NWB followed by weight-bearing 2 weeks

f. Tongue and joint depression fractures: i. Closed reduction ii. Open reduction (extensive)

b. A plate stabilizing the lateral wall (the plate is the key in preventing the posterior heel from drifting into varus)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, and lock in the medial cortices before the lateral-to-medial lag screws are inserted

7. Further considerations of treatment of intra-articular fractures:a. Displaced intra-articular calcaneal fractures require open reduction in order to restore joint congruencyb. The Essex-Lopresti maneuver can be used in elderly patients with intra- articular tongue-type fractures who cannot tolerate surgery

c.

Summary of correction: If there is visual congruency of the subtalar joint, visual alignment of the fracture through Gissane's angle, and radiographic absence of an intra-articular step off at the posterior facet with reduction of the medial wall on the axial view, then reduction must be considered anatomic

c. A transverse K-wire is inserted through the calcaneus to attach a Kirschner traction device for manipulation (traction reduces the medial wall) d. A bone graft would not be necessary if adequate lateral to medial wall reduction is performed. However, some feel that a bone graft is necessary under the posterior facet after it has been elevated from the body of the calcaneus

NOTE* The Essex-Lopresti maneuver is a technique of reduction. The patient is taken to the OR and using fluroscopic control, a Steinmann pin is driven into the posterior tuberosity from the posterior aspect of the heel. The pin is then used as a lever to elevate the impacted and depressed joint surface and tongue portion. This is accomplished by pushing the protruding portion of the pin downward toward the plantar aspect of the heel. 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 second pin may be driven parallel to the first for added fixation. A BK cast is applied

8. Surgical incisions:a. 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 nervei. McRenolds horizontal incisionii. Stephenson vertical incisioniii. Zwipp medial "L" incisionb. Lateral approach: Gives expansile exposure to the lateral wall of the calcaneus, the calcaneocuboid joint and most importantly the posterior facet (site of major pathology)i. Modified -Kocher incisionii. Oilier incisioniii. Right angle incision (consists of a vertical and horizontal arm; an excellent expansile incision which exposes the entire lateral rearfoot complex via a subperiosteal flap, and can be extended proximally if a concomitant ankle

fracture is present)

9. Complications of Calcaneal Fractures: a. Heel painb. Peroneal tendonitisc. Osteoarthritis of the STJ, MTJ, and ankle joint d. Heel pad damagee. Bony prominencef. Flexor tenosynovitisg. Sural or posterior nerve entrapment h. Calcaneus gait (weak plantarflexion) i. Rigid pes planusj. Reflex sympathetic dystrophy k. Infection

NOTE* The 4 areas to consider when evaluating the intra-articular fracture of the calcaneus are posterior facet disruption, medial wall (determines height), lateral wall blow out (determines width) and calcanel cuboid jointa. 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. Medial wall pathology: 1 cm or more displacement of the medial wall is indicative of increased shortening and increased width, and should be treated with ORIFc. Lateral wall pathology: Lateral wall disruption can cause sural nerve irritation and peroneal tendon dysfunction, therefore should be reduced d. Calcaneal cuboid joint: Involvement can be treated with closed reduction

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

NOTE* In cases of severe comminution, the question of primary subtalar fusion or triple arthrodesis is still debated

Talar Fractures1. Anatomy:a. 2nd largest tarsal bone with more than 1 /2 the surface being cartilage b. No muscular or tendinous attachmentsc. The 3 main parts are the head, body and neck. The neck deviates medially 15-200 and is its most vulnerable partd. The FHL lies within a groove on the posterior talar tubercle held by a retinacular ligamente. Inferiorly 3 facets are present; 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. Blood supply:a. Extraosseous blood supply comes from:i. Posterior tibial (#1)ii. Anterior tibial (#2)iii. Perforating peroneal (#3)b. The talar neck is supplied by an anastamosis of 2 vessels:i. Artery of the tarsal sinus ii. Artery of the tarsal canal

3. Classification:a. Chips and avulsions b. Compression fractures c. Fractures of the body:i. Non displacedii. Displacediii. Comminutedd. Fractures of the neck (Hawkins' classification): All caused by some fall oraccident resulting in a severe dorsiflexory force to the footi. Group 1: Vertical fracture of the neck that is undisplaced One of the three sources of the blood supply is disrupted (a 13% chanceof avascular necrosis has been reported)ii. Group 2: Vertical fracture of the neck that is displaced, the STJ issubluxed or dislocated, and the ankle joint is WNL Two main sources of blood supply are interrupted (a 42% chance ofavascular necrosis has been reported) Prognosis is related to the development of avascular necrosisiii. 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. 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, following injury, which indicates healing is occurring

e. Fractures of the talar dome (Berndt and Harty): see sectionOsteochondral fracturesf. Dislocations:i. Anterior dislocations ii. Posterior dislocations iii. Lateral dislocations iv. Medial dislocations v. Total dislocation

4. Treatment:a. Talar neck:i. Group 1: BK/NWB cast for 6-12 weeks, followed by NWB with no cast for an

additional 2-5 months with ROM ankle excercises (prognosis is excellent) ii. 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. Group 3: ORIF with accurate anatomical reduction must be achieved followed by

BK/NWB cast for 3-4 months (prognosis is poor) iv. Group 4: As per Group 3

NOTE* Early anatomical reduction in displaced fractures yields the most favorable long term results

NOTE* If the talus must be removed, a Blair procedure is recommended

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.

NOTE* Arthrodesis procedures have been stated to give better results as a secondary procedure than a talectomy alone

a. 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. An additional blood supply courses into the undersurface through the talocalcaneal ligamentb. The talus must be reduced as quickly as possible to protect any remaining blood supply by untwisting and reducing tension in the deltoid ligament, and to encourage revascularizationc. An atraumatic operative approach is needed that allows adequate visualization for anatomic reduction (Oilier lateral incision, transverse Cincinnati incision or a posterolateral vertical incision work well)

b. Lateral process:i. Undisplaced: BK cast partial weight bearing 4 weeks i. Displaced: Excision of bone fragment if symptomatic

c. Total talar dislocations (out of the ankle mortise and STJ, anterior to the fibula, head directed medially, talus rotated on the longitudinal axis so its inferior aspect points posteriorly):i. Manipulation: Usually not successful but should be attempted ii. Skeletal traction: Steinmann pin through calcaneus attached to traction apparatus to

achieve an open space between the tibia and calcaneus. The assistant inverts and plantarflexes the foot, as the surgeon presses both thumbs on the posterior aspect of the talus by inward and backward movement to rotate the talus. Afterward, 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°. This is followed by a BK cast for 6-8 weeks. Avascular necrosis is inevitable.

If there is an open wound treat appropriately.

Osteochondral Fractures1. Classification (Berndt and Harty):a. Stage 1: A small area of compression of subchondral boneb. Stage 2: A partially detached osteochondral fragmentc. Stage 3: A completely detached osteochondral fragment remaining in the defect.d. Stage 4: A displaced osteochondral fragment

2. Mechanism of injury:a. Lateral lesions: Inversion and dorsiflexionb. Medial lesions: Inversion, plantarflexion and lateral rotation of the tibia on the talus

3. Diagnosis:a. Stage 1:i. Usually no symptoms, and has been diagnosed as an ankle sprainii. ROM of the ankle is WNL and painlessb. Stage 2:i. Painful with associated collateral ligament damage Lateral dome lesions have pain over the lateral collateral ligaments Medial dome lesions have pain over the deltoidii. Ankle ROM may be limited due to traumatic synovitisc. Stage 3 8 4:

NOTE* It has been found that 44% are lateral and anterior, and 56% are medial and posterior. Lateral lesions are shallow wafer shaped and medial lesions are deep cup shaped

i. Pain is more severeii. Decreased ROM of the ankle, joint locking or crepitus, and/or instability of the collateral ligaments

4. Treatment:a. Conservative: For stage 1, 2, 3 medial lesions via NWB BK cast for 6 weeks followed by a patellar-bearing brace until the fracture heals b. Surgical: For stage 3 lateral and 4, surgery to remove fragment, or stabilize fragment using K -wire or Herbert screw

Staging System for Osteochondral Lesions

Radiographs T2W-MRI ArthroscopyStage 1 Normal Marrow edema

(diffuse high signalintensity

Normal orirregularity andsoftening ofcartilage

Stage 2 Semicircularfragments

Low signal line surrounds fragment

Articular cartilagebreached, definablebut nondisplacedfragment

Stage 2A Subcortical lucency High-signal fluid within fragment

Stage 3 Semicircular High signal line Displacable

Stage 4fragmentLoose body

surrounds fragmentDefect talar dome

fragmentLoose body

Note* The diagnosis can be made on x-ray (the A-P view shows the medial talar dome clearly, the lateral dome is obscured but can be visualized in the medial oblique), but the use of tomograms or CT are best

NOTE* Review of the literature reveals that surgically treated patients have better results in preventing post-traumatic arthritis. However, conservative vs. surgical treatment depends upon the size/location/stage of the fracture fragment

Navicular Fractures

1. Anatomy:a. Cancellous bone which is convex distally where it articulates with the three cuneiforms and is concave proximally to accomodate the talar head b. The dorsal navicular surface is roughened and serves as an attachment for the dorsal talonavicular ligament, cuneonavicular ligaments and the cubonavicular ligamentc. The plantar surface is so roughened and is invested by the plantar calcaneonavicular ligament (spring ligament)d. The lateral surface serves the attachment for the navicular portion of the bifurcate ligamente. The navicular tuberosity provides the major attachment site for the posterior tibial tendonf. 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. Navicular Fracture Classification by Watson-Jones a. Type I- Fracture of the tuberosityi. Relatively common as compared to other typesii. The mechanism of this fracture is acute eversion of the foot causing an avulsion-type fracture, caused by increased tension placed on the tibialis posterior tendoniii. These fractures are generally non-displaced because of the multiple soft tissue attachments to the tuberosityiv. Best demonstrated radiographically on the AP and oblique x-ray with the foot in moderate equinusv. It is important to differentiate this fracture from a type II accessory navicularvi. If the type I fracture is severely displaced you should suspect calcaneocuboid involvementvii. The combination of a severely displaced fracture and compression fracture of the cuboid and/or calcaneus is referred to as the NUTCRACKER SYNDROMEvii. Treatment is with an Unna-type boot of BK partial weight-bearing cast x 4 weeks.viii. If a symptomatic non-union occurs it is recommended that the fragment be

Fractures of the navicular are easily missed,, 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. Isolated fractures are uncommon, and usually occur in conjunction with Lisfranc's dislocations and fractures of the rearfoot. Stress fractures of the navicular have been seen in runners but more frequently in basketball players, and this problem is often misdiagnosed as anterior tibial tendonitis

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 intraarticularii. The mechanism of injury is plantarflexion of the foot followed byeither 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 supranavicularev. Treatment is with a BK partially weight-bearing cast for 4-6 weeksvi. 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 jointsii. 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 markedplantarflexion position at the moment of impact iv. These fractures are usually intraarticularv. DP, lateral, and oblique x-rays will demonstrate the fracturevi. A differential diagnosis for a type Ill navicular fracture include a bipartite tarsal navicular and lithiasis of the navicularvii. Treatment of nondisplaced fractures is with a BK walking cast for 6-8 weeksviii. Treatment of displaced fractures is with ORIF and a BK non-weight-bearing cast for 6-8 weeks

e. Type IV- Stress fracture of the navicular

i. Usually an athletic injury, most commonly track and fieldii. Symptoms are increased pain with activity, and decreasing painfollowing the activityiii. Usually intraarticulariv. Usually found with either a bone scan, CT scan, or MRIv. Early diagnosis is important to prevent a complete fracture and an eventual nonunionv. 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)

Cuboid Fractures The cuboid is a key bone in the rigid lateral column of the foot. Its position is stabilized by several structures to ensure its structural and functional integrity1. Anatomy:a. The cuboid is locked in articulation with 5 bones of the foot (4th and 5th metatarsals, calcaneus, lateral cuneiform, and a fibrous articulation with the navicular)b. Primarily cancellousc. Dorsally, the bifurcate ligament attaches the calcaneus to the cuboid, the dorsal cuneocuboid ligaments tether the cuboid to the lesser tarsusd. Dorsolaterally, the dorsal tarsometatarsal ligaments attach the cuboid to the metatarsal basese. Plantarly, the long and short plantar ligaments attach to and cross the cuboid while adding to the maintenance of the longitudinal arch f. The sural nerve and lesser saphenous vein cross over the cuboid areag. The peroneus longus courses plantarly under the peroneal groove in the cuboidh. The arterial supply is made up of an arterial rete system supplied by the lateral malleolar artery, the lateral tarsal artery and the arcuate artery

2. Classification system:a. Type 1: Stress fractureb. Type 2: Avulsion fractures(a) Bifurcate ligament area(b) Tarsometatarsal ligament areac. Type 3: Body fracture, nondisplacedd. Type 4: Indirect crush fracture or nutcracker fracture e. Type 5: Plantar dislocationf. Type 6: Direct crush

3. Avulsion Fractures:a. Most common on the lateral aspect at the calcaneocuboid joint and the 5th met-cuboid articulation.b. Avulsion fracture of the tuberosity due to tension on inferior calcaneocuboid ligament.c. Adduction of the cuboid on the calcaneus will result in avulsion due to tension on lateral calcaneocuboid ligament.

d. Treatment is closed reduction with casting

4. Fractures of the body of the cuboid:a. Due to axial rotary forces while the foot contacts the ground in a plantarflexed position- usually associated with fracture of the base of the 5th

NOTE* Avulsion fractures of the cuboid must be differentiated from os cuboid secondarium, os peroneum and/or os vesalianum

metatarsal and calcaneusb. Crush fracture as above mechanism but with more force (a nutcracker effect)c. Treatment is closed reduction with BK cast 6-8 weeks or arthrodesis in case of crush fracture

5. Stress fractures:a. Should be suspected if concerned about peroneus longus tendonitis, calcaneocuboid arthritis, dropped cuboid, and capsulo-ligamentous strain in the cavus foot type.b. Treatment: BK cast 6-8 weeks (first 2 weeks NWB)

Cuneiform Fractures1. Avulsion fractures:a. Usually located on the medial aspect of the internal cuneiform as an avulsion due to pull of the tibialis anterior

2. Fractures of the body:a. Mechanism: Either by direct trauma or rotational force

3. Stress fractures:a. Diagnosed by bone scans, CT, or tomography b. Treated with BK WB cast

4. Treatment: Requires traction to reduce the dislocation and allow anatomical reduction of the cuneiforms to prevent chronic pain and arthritis

Fifth Metatarsal Base FracturesFractures of the 5th metatarsal are commonly associated with inversion sprains of the ankle, therefore, with any ankle inversion injury, the 5th metatarsal base should always be evaluated. This is the Stewart Classification

NOTE* In general, treatment for type 1, 2, and 3 injuries is usually NWB BK cast for 6-8 weeks. Avulsion fractures are sometimes opened if the dislodged fragment is felt to be intraarticular or will cause impingement on the peroneal tendons. Type 5 dislocations must be reduced, with closed reduction under general anesthesia attempted first with an inversion-adduction force on the forefoot while pushing the cuboid up from the arch. If this fails, open reduction is advised. Type 4 fractures usually require autogenous bone grafting for anatomic alignment of the calcaneocuboid and tarsometatarsal joints

NOTE*a. Cuneiform fractures are usually associated with Lisfranc dislocationsb. The mechanism of the dislocation and fractures of the cuneiforms involves the forefoot and rearfoot acting as levers, with the lesser metatarsals displaced laterally and dorsallyc. Fracture of the 2nd metatarsal base is an important factor in causing dislocation or fracture of the middle cuneiformd. Lisfranc's ligament interruption has an effect on a middle cuneiform fracture/dislocation

1. Type 1: A true Jone's fracture which occurs between the epiphysis and diaphysis (metaphyseal level).a. Usually oblique or transverse in natureb. Situated at the distal end of the articular capsule above the intermetatarsal ligamentsc. The mechanism of injury is internal rotation of the forefoot while the base of the 5th metatarsal remains fixed, The capsule is only stretched and the peroneus brevis takes practically no part on the injury d. Upon physical examination, extreme mobility of the shaft of the 5thmetatarsal is founde. This is an unstable fracture with a very poor blood supply and because of this, this fracture has a very high propensity for non-unionf. Treatment is with a non-weight-bearing cast BK cast for 4-6 weeks, or Ifdisplaced, then ORIF

2. Type 2: Intraarticular fracture of the 5th metatarsal base with one or two fracture linesa. A result of shearing force caused by the internal twisting of the forefoot while the peroneus brevis is contractedb. Displacement of the fragments depends upon the extent of the damage to the capsule and ligamentsc. Treatment is with an Unna-type boot or BK non-weightbearing cast for 4-6 weeks, or if nonreducible, then ORIF

3. Type 3: This is an avulsion fracture of the base of the 5th metatarsala. This is oftentimes mistaken in the literature for a Jones fracture. It is the most proximal injury, where a small fragment is torn away, the fracture is extraarticular, and the fracture line is usually at right ankles to the long axis of the metatarsal basea. The mechanism of injury is primarily a sudden sharp contraction of the peroneus brevis when the ankle is in plantarflexionb. The treatment is with an Unna-type boot of BK non-weightbearing cast for

4-6 weeks, or if nonreducible then ORIF with tension bend wiring or screw fixation. If the fragment is too small for fixation, then excision of the fragment and reattachment of the peroneus brevis tendon is recommended

4. Type 4: This is a comminuted intraarticular fracture of the 5th metatarsal basea. The mechanism of injury is similar to Type 2, but in this case the 5th metatarsal base gets crushed between the cuboid and the ground causing fragmentationb. There is a high rate of non-unionc. Treatment is an Unna-type boot or a BK non-weight-bearing cast for 46 weeks, or if fracture fragments are severely displaced, bone grafting and ORIF may be required

5. Type 5: A fracture that occurs in children, where there is a partial avulsion of the epiphysis with or without a fracture line or hairline crack as seen in Type 2. This fracture can also be classified as a Salter-Harris I. a. The treatment is a BK non-weight-bearing cast for 4-6 weeks

Metatarsal Fractures (1st and 2nd-3rd-4th)1. Classification: a. Site:i. Epiphysealii. Diaphysealiii. Metaphyseal b. Type:i. Incomplete separation of the bony fragmentsii. Complete separation iii. Greenstick fracture iv. Buckle type fracturec. Configuration:i. Transverse ii. Spiral

iii. Obliqueiv. Comminutedv. Stress fracture

d. Relationship of the fragments:i. nondisplacedii. Displaced: Shifted sideways Rotated Distracted Overriding Angulated Impactede. Relationship to outside environment:i. Simpleii. Compound

2. Treatment:a. Closed reduction with BK NWB cast 4-6 weeksb. Open reduction:i. Monofilament wire ii. K-wiresiii. AO technique

3. First metatarsal fractures:a. Anatomy:i. Articulates laterally with the 2nd metatarsal, proximally with the medial cuneiform, and distally with the base of the proximal phalanx of the halluxii. 2.7 cm proximal to the head of the 1 st metatarsal (on the lateral aspect) is the foramen for the nutrient artery

NOTE* If, wound is open treat accordingly :(check blood loss, shock etc) tetanus prophylaxis, antibiotic therapy, skin coverage as necessary, rigid reduction of fracture, and fluid replacement as necessary

NOTE* Salter devised a classification system describing fractures of long bones1. Location of the fracture: diaphysis, metaphysis, physis, epiphysis, intraarticular 2. Extent of the fracture: complete or incomplete3. Arrangement of the fracture: transverse, spiral, oblique, compression, comminuted

NOTE* Complications include pseudoarthrosis, avascular necrosis, 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). and Iselin's disease (osteochondrosis) Also differentiation should be made between an avulsion fracture and an os vesalianum and os perineumNOTE* Radiographic evidence of chronicity is manifested by a wide

radiolucent fracture line, periosteal reaction, thickening of the lateral margin of the cortex adjacent to the fracture with or without callus, and intramedullary sclerosis

iii. Plantar surface is concave, causing this side to be under tension during weight bearingiv. Holds the sesamoids, the tibial being larger separated by the crista or central ridge (if more than 2 sesamoids, bipartite indicating multiple ossification centers)v. Muscles around the 1st metatarsal: Peroneus longus: involved in 1st metatarsal base avulsion fractures Tibialis anterior EHL EHB Adductor hallucis Abductor hallucis FDB Tibialis posteriorvi. Arterial supply is the dorsalis pedis and 1 st plantar metatarsal

b. Classification:a. Salter classification is based on 6 categories i. Site: anatomical locationii. Configuration: transverse, oblique, spiral, etc. iii. Open or closediv. Locationv. Extent: complete or incompletevi. Relationship of the fracture fragments to each other: displaced, angulated, rotated, etc.

c. Treatment:i. Simple fractures with no displacement are treated NWB BK cast for 6-8 weeksii. Displaced fractures should be anatomically reduced (usually open reduction ORIF)iii. Open fractures: treated as per open fracture classification

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

5. Internal metatarsal fractures (metatarsals 2-3-4): Treated like the other metatarsal fractures

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

Ankle Fractures1. Classifications:a. Lauge-Hansen: A two-word description indicating the position of the.foot at the time of injury, and the direction of the talus. Five types ofinjuries listed:i. Supination-Adduction ii. Pronation-Abductioniii. Supination-External Rotation iv. Pronation-External Rotation v. Pronation-Dorsiflexion

b. Danis-Weber: Based on the location of the fracture of the fibula and is useful for determining the appropriate form of treatment for ankle fractures.i. Type A: Below the joint levelii. Type B: At the level of the jointiii. Type C: Above the level of the joint

2. Lauge-Hansen:a.

Supination-Adduction:i. 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. Stage 11: Stage I plus an oblique fracture of the medial malleolus (pushoff)

NOTE* The major advantage of the classification is to enable the examiner to assess the stability of the ankle from the x-rays by predicting ligamentous injuriesIn external rotation injuries, the progression of lesions simply follows the anatomic sequence around the ankle joint: deltoid-medial malleolus complex, anterior syndesmosis, fibula, and posterior syndesmosis.

In supination injuries, the sequence starts with the anterior syndesmosis, and in pronation injuries, with the deltoid-medial malleolus complex.

NOTE* The hallmark of this injury is an avulsion fibular fracture at the level of the ankle or below.

NOTE* Variants of Stage If S -A injuries are: rupture of the deltoid ligament rather than fractures of the lateral malleolus, concomitant damage to the tibiofibular syndesmosis with fracture of the medial and lateral malleolus, avulsion fracture of the lateral malleolus proximal to the A.T.F. with damage to the lateral collateral ligament, S-A fracture of the medial malleolus without injury to the lateral side,

NOTE* Healing is more favorable with supination injuries (less overall damage)

b. Pronation Abduction:1. Stage I: Fracture of the medial malleolus or tear of the deltoid ligamentii. Stage II: Stage I plus rupture of the anterioinferior tibiofibular and posterioinferior tibiofibular ligaments and transverse tibiofibular ligament, with fracture of the posterior lip of the tibiaiii. Stage III: Stage II plus an oblique supramalleolar fracture of the fibula (the antero-posterior tibiofibular ligaments tear but the interosseous ligament does not)

c. Supination-External Rotation:

i. Stage

NOTE* This is the most common fracture of the ankle, and its hallmark is a spiralfracture of the fibula

I: Rupture of the anteroinferior tibiofibular ligament, sometimes with avulsion of the bony fragment between the tibia and fibula. (tibia: Chaput, fibula: Wagstaff)ii. Stage II: Stage I plus a spiral oblique fracture of the lateral malleolus.iii. Stage III: Stage 11 plus a fracture of the posterior lip of the tibia (Volkmann's fracture)iv. Stage IV: Stage III plus a fracture of the medial malleolus

d. Pronation-External Rotation:

i. Stage I: Fracture of the medial malleolus or a tear of the deltoid ligament.ii. Stage II: Stage I plus a tear of the anteroinferior tibiofibular ligament and interosseous ligament.iii. Stage III: Stage II plus an interosseous membrane tear and a spiral fracture of the fibula 7-8 cm. proximal to the tip of the lateral malleolus iv. Stage IV: Stage III plus a fracture of the posterior lip of the tibia.

NOTE* 'The hallmark is a high fibular fracture.

e. Pronation-Dorsiflexion:i. Stage I: Fracture of the medial malleolusii. Stage II: Fracture of the anterior inferior aspect of the tibiaiii. Stage Ill: Supramalleolar fracture of the fibula (transverse)iv. 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, where there is pronation-dorsiflexion injury, axial compression is present, which will result in the following fractures of the tibial plafond:a. if the talus is dorsiflexed upon impact, anterior portion of tibial plafond is fracturedb. if the talus is plantarflexed upon impact, posterior portion of the tibial plafond fracturesc. if the talus is in neutral position upon impact, central shattering of the articular surface of the tibial plafond takes place

3. Danis-Weber fractures:a. 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. It is associated with a vertical fracture of the medial malleolus.b. Type B (Supination-external rotation or Pronation-abduction Lauge-Hansen): An avulsion fracture of the medial malleolus and fracture of the fibula that begins at the level of the tibial plafond. The posterior rim of the tibia might also be fracturedc. Type C (Pronation-external rotation Lauge-Hansen): Characterized by rupture of the syndesmosis and a fibular fracture that is located above the tibial plafond. Associated injuries are an avulsion fracture of the medial malleolus or deltoid ligament rupture and a large or small posterior malleolar fracture.

4. Other fractures:a. Tillaux fracture: Fracture of the anterior tubercle of the tibia due to tension of the IATF ligament. Also a type 3 epiphyseal injury of the anterolateral distal tibia.b. 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 , associated with tibiofibular diastasis.d. Pankovich classification of Wagstaff fractures:i. Type l: Avulsion fracture and fibular fragments remaining attached to the anterior talofibular ligament and IATF ligamentii. Type Il: Oblique fracture with fragment remaining attached to the IATF ligamentiii. Type III: Oblique fracture of the fibula in addition to a fracture of the anterior tibial tuberclee. Bosworth fracture: Fibular oblique fracture caused by external rotation but the fracture occurs after posterior dislocation of the fibula. This causes closed reduction to be impossible.f. Frost. fracture: A triplane fracture which is a combination of Tillaux and Salter-Harris Type 2 occurring at the distal tibiag. Pott's Fracture: A fracture of the distal fibula and disruption of the deltoid ligament (or medial malleolar fracture)h. 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, medial malleolus, and the anteromedial portion of the epiphysis; the second consists of the remainder of the metaphysis, epiphysis, and attached fibula.i. Chaput's tubercle: The anterolateral tubercle of the distal tibiaj. Shepherd's fracture: Fracture of the posterolateral tubercle of the talus. k. Volkmann's fracture: A fracture of the posterolateral corner of the distal tibia (Volkmann's triangle), medial malleolus, fibular shaft, and tibiofibular diastasis.

l. 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. 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. Thurston-Holland sign: The spike of metaphyseal bone attached to the fractured epiphysis seen with Salter-Harris 2 fractures.

4. Treatment of ankle fractures:a. General considerations: A decision to perform surgery takes in account all aspects of the patient's condition. In general, 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 earlyrange of motion and early weight-bearing. Early ORIF should be done provided that the initial evaluation of the patient reveals a satisfactory .neurovascular status and skin condition of the foot. Early ORIF reduces swelling by stabilizing the fracture and also reduces bleeding. If the fracture is open, the wound should be cultured and broad spectrum IV antibiotics started, followed by wound debridement, irrigation, and ORIF as indicated. The wound is left open and delayed primary closure is performed at least 5 days later. Closed reduction of displaced ankle fractures rarely accomplishes restoration of normal anatomy without repeated forced manipulations, and does not allow for early ambulation and range of motion.

b. Absolute criteria:i. Fractures and dislocations must be reduced immediatelyii. All joint surfaces of the ankle must be anatomically reduced iii. Reduction must be maintained while the fractures are healing iv. Motion of the joints should be started as soon as possible

c. Other criteria:i. ORIF of the fibula should precede fixation of the medial malleolus because it provides a buttress to the talus, which tends to displace laterally and pull along the medial malleolus. Shortening of the fibula must be prevented (see chapter 29: Ankle Conditions, Nonunion of Malleoli)ii. Repair of the deltoid is difficult and rarely necessary, and should be reserved for more severe injuries in which soft tissues around the ankle are damaged.iii. Large displaced fragments of the anterior and posterior processes of the tibia, which are present in some indirect ankle fractures, 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. Fracture of Chaput tubercle and Wagstaff fractures should always be reduced and fixedv. A displaced yet essentially intact fibula requires syndesmotic screws for proper reduction

NOTE* ORIF is indicated for all ankle fractures with a greater than 2 mm. lateral or posterior displacement of the lateral or medial malleolus

d. Fixation of the fibula: Should be fixed prior to the medial malleolus i. 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 usedii. 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 usediii. 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, it is critical to reduce the fracture anatomically in

order to avoid penetration outside the bone

e. Fixation of the medial malleolus: Requires fixation with a device that provides compression between the fracture fragments I. AO technique: Essentially only 4.0 mm cancellous screws should be used for fixation of

the medial malleolus (self-tapping 4.5 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. Closed reduction:i. The main advantage of closed reduction is lack of postoperative wound complicationsii. Closed reduction is contraindicated in unstable ankle fractures in which both malleoli are fracturediii. Closed reduction is acceptable in fractures when open reduction is contraindicated (vascular compromise, neglected open fractures, pyoderma,

NOTE* Stability of the syndesmosis is tested by pulling the fibula laterally with a bone hook. When there is more than 2-3 mm of lateral displacement of the fibula, instability is present and the use of a syndesmotic screw(s) is indicated. It is desirable to insert this screw 2-3 cm above the tibial plafond. When there is a plate attached to the fibula, one cortical screw can be removed and replaced with a syndesmotic screw. When drilling for a syndesmotic screw, the direction must be anteromedial to avoid inserting the screw posterior to the tibia

NOTE* Observe for tendon dislocations, i.e. posterior tibial tendon into the ankle joint

skin necrosis or contusion)iv. 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. 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, then is

extended to a long leg cast with the knee in 30° of flexion. A minimum of 6 weeks of immobilization is required

5. Factors that result in irreducible fractures: a. Interpositon of the deltoid ligamentb. Trapping of the tibialis posterior tendon c. Trapping of the medial tendon(s)d. Dislocation and fracture-dislocation of the fibula behind the tibia

6. Soft tissue complications of fractures and dislocations of the ankle:a. Skin: Blistering, decubitus breakdown, slow wound healingb. Massive Edema: Treat with compression immediately, cold application, elevation, rigid internal fixation and early ROM c. Fracture blisters: Direct result of edema. ORIF must be delayed for 3-7daysd. DVT's: Due to plaster immobilization, venous insufficiency, sickle-cell.Treat casted patients with sub-Q heparin 2500-5000 units Q 8-12 hours ifthey are at riske. Chondrolysis of the ankle (cartilage necrosis): Leads to posttraumaticarthritisf. Avascular necrosis of the talusg. Infection following open fractures (5-30%)h. Nerve injuriesi. Nerve disruptions (complete and incomplete)ii. Reflex sympathetic dystrophy syndromei. Arterial injuriesj. Tendon injuries k. Ligament injuriesi. Medial deltoidii. Lateral ligament (chronic thickening, local tenderness, inversioninstability, anterior subluxation)

7. Bony complications of fractures and dislocations of the ankle:a. Fractures of the lateral malleolus:i. Non-union and malunion (external rotation) with chronic swelling andwidening of the ankleb. Fractures of the medial malleolus:i. Non-union: More common than the lateral malleolus due to soft tissueinterposition between the fragments Chronic diastasis Loose bodies Arthritic changesc. Fractures of the posterior tibial margin: Greater than 25% margin rendersthe ankle unstable leading to posterior subluxationi. Posterior subluxation Medial and lateral malleoli and syndesmosis tornii. Malunion with posterior subluxation Most common complicationd. Fractures involving the distal tibiofibular syndesmosis:i. 2nd only to plafond injuries, leads to arthrodesis of the ankleii. Mortise wideninge. Vertical or Pilon fractures of the distal tibia: i. Varus or valgus deformity ii. Traumatic arthritisiii. Articular incongruityf. Epiphyseal injuries:i. Articular incongruity is the main concern

ii. Vascular embarassment iii. Posttraumatic arthritis iv. Varus or valgus deformity of the ankle v. Angular deformityvi. Leg length discrepancy vii. Bone and joint sepsis

Midtarsal Joint DislocationsThe 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. Injuries are rare 1. Classification (Main and Jowett): Midtarsal joint injuries are defined according to the direction of the force producing the dislocation. a. Medial force results in three grades of injuries:i. Fracture sprain of calcaneus, talus, navicular, or cuboidii. Fracture/subluxation or dislocation with medial subluxation or dislocation of forefoot while the talocalcaneal relationship remains normaliii. Swivel dislocation with only the T-N joint dislocating b. Longitudinal force injuries:i. Fracture of the navicular takes placec. Lateral force injuries:i. Fracture sprain of the navicular tuberosity, dorsal chip of the talus or navicular, and lateral fracture of the cuboidii. Fracture/subluxation will result in T-N lateral subluxation and nutcracker fracture of the cuboidiii. Swivel dislocation with the talus dislocating laterally relative to the naviculard. Plantar force injuries:i. Result in dorsally dislocated talus and calcaneus relative to the navicular, and cuboid chip fractures also present dorsally, as well as anteroinferior calcaneal fracturese. Crush injuries: Have variable patterns. Usually associated with open wounds

2. Treatment:a. Medial force injuries: reduced by traction and reversal of the mechanism of injury with casting (WB or NWB)b. Lateral force injuries: closed reduction first. C-C fusion is recommended for persistent symptoms. Triple arthrodesis has been the traditionally recommended treatment if conservative care has failed

Tarsometataral Joint Dislocations/Fractures (Lisfranc dislocation)

1. Mechanism of injury:a. Abduction and plantarflexion: 2nd metatarsal is fractured, the remaining ligaments give way and the forefoot is subluxed laterally b. With continued abduction, there may be a nutcracker-like fracture of the cuboid.

2. Classifications:a. Hardcastle et. al.i. Type A: Total incongruity (the metatarsals displace in a unit in one planeii. Type B; Partial incongruity ( at least one of the tarso-metatarsal joints is not displaced)iii. Type C: Divergent (the 1 st metatarsal is displaced medially and the other metatarsals are displaced laterally) b. Quenu and Kussc. Myerson: Further subdivided Hardcastle's classification i. Type A: Total incongruityii. Type 131: Partial incongruity, medial metatarsals iii. Type B2: Partial incongruity, lateral metatarsals iv. Type C: Divergent patterns v. Type Cl: Partial displacement vi. Type C2: Total displacement

3. Diagnosis: Via x-ray (A-P & lat)/tomography (A-P)/CT scana. Widening between the base of the 1 st and second metatarsals or the middle and medial cuneiforms is often present. This widening can also be between the base of the second and third metatarsals or middle and lateral cuneiforms.b. 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.c. Projected lines from the base of the metatarsals should not intersect the corresponding cuneiforms or cuboid.d. Angulation of the metatarsals can occur without apparent fracture at the base.e. Widening between the base of the 5th metatarsal and the cuboid can

This type of injury occurs in conjunction with high energy trauma (equestrian injuries) as well as minor twisting injuries, which are also associated with injuries to the cuneiforms, cuboid, and the navicular. The key to understanding this injury is the structural integrity provided by the slotting in the base of the second metatarsal, which is surrounded by 5 adjacent bones that create a tight mortise. There is no ligament between the base of the 2nd and 1st metatarsals, but a ligament extends from the medial base of the 2nd metatarsal obliquely to insert into the medial cuneiform.Soft tissue loss and vascular impairment can be a major problem in this settingThe 2nd metatarsal is the key to stability of Lisfranc's joint.The dorsal tarsometatarsal ligaments are weaker than the plantar tarsometatarsal ligaments.

occur.

4. Treatment: Includes splinting, casting, closed reduction and casting, closed reduction and percutaneous pinning, or open reduction and percutaneous pinning (according to type)a. If instability is present but alignment is anatomic with release of the force, immobilizing the extremity in a BK NWB cast is appropriate.b. If instability is present and alignment is not anatomic with release of force, then pinning (open or closed) is mandatory followed by casting.c. If severely unstable, then open anatomic reduction with heavy gauge K - wires or screw fixation is the procedure of choice. d. With severe joint comminution, primary arthrodesis may be considered

NOTE* Due to the spontaneous relocation that this fracture dislocation can produce, x-rays do not usually show the true magnitude of the severity of this injury

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

NOTE* Always pin the 2nd metatarsal base

5. Complications:a. Amputationb. Sepsisc. Thrombophlebitisd. Compartment syndromee. Neuroma formation (either traumatic or postsurgical “amputation” type) f. Post-traumatic arthritis

Ankle Inversion SprainAlso see Chapter 29, Ankle Conditions: Chronic Lateral Ankle Instability

Inversion sprains by definition involve lateral ligament disruption. The anterior talofibular ligament resists internal rotation, plantarflexion, and anterior subluxation of the talus. The posterior talofibular ligament functions to reinforce the ankle joint and the calcaneofibular ligament functions to resist adduction forces.1. Anatomy:a. Lateral ligaments:i. Anterior talofibular (ATFL) (intracapsular): The primary stabilizing structure preventing anterior displacement of the talus (fan shaped). ii. Calcaneofibular (CFL) (extracapsular)iii. Posterior talofibular (PTFL) (intracapsular/extrasynovial): The thickest and strongest and the least likely to be injured iv. Lateral talocalcaneal ligament

2. Ligament composition:a. 67% waterb. Remaining 33%: 90% collagen type 1, elastin, and glycosaminoglycans

NOTE* Most feel that stability and anatomic reduction depends upon the 2nd metatarsal, so that if the 2nd metatarsal relocates, all the other metatarsals will follow if there is no damage to the intermetatarsal ligaments

Definition: A sprain is a disruption of fibers, a strain is plastic deformation with elongation

NOTE* PTFL is 20-45° posteroinferior to the fibular bisection so allows STJ range of motion.NOTE* Inversion of the ankle is resisted primarily by the ATFL when the ankle

is plantarflexed and by the CFL when the ankle is dorsiflexed.

NOTE* Angular relationships between the ATFL and the CFL is 100° in the frontal plane and 105° in the sagittal plane. This sagittal plane angle decreases with STJ supination and increases with STJ pronation. 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.

3. Causative Factors:a. Tibial varumb. Calcaneal varumc. Plantarflexed -1st rayd. Rigid forefoot valguse. STJ varumf. Uncompensated equinusg: Muscle imbalance (peroneal insufficiency)h. Previous sprains (elongated ligaments no longer restrain inversion) i. Torsional abnormalitiesj. Short leg syndromek. Ankle varus

4. Mechanism of injury:a. Internal rotation, plantarflexion, and adduction of the talus beyond normal physiologic limits

5. Classifications of inversion ligamentous injuries (mechanism of injuries): a. Leach (1983)i. 1 st degree (ATFL rupture)ii. 2nd degree (ATFL, CFL, and capsule rupture)iii. 3rd degree (all three ligaments and capsule)b. 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. Supination-inversion (with a plantarflexed ankle or a neutral ankle) ii. Supination internal rotationiii. Supination plantarflexion

6. Diagnosis:a. Scout filmsb. Stress views (local anesthesia: peroneal block + local ankle infiltration):Can use a Telos® apparatus for better quality controli. Inversion stress: A 5-6° difference between the injured and uninjured ankle signifies ligamentous rupture

NOTE* Additionally, 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 CFLType III: a total rupture of the ATFL, CFL, PTFL, and capsule or tearing of the ligaments

ii.

Push-pull stress (anterior draw sign): The ability to pull the ankle out of the mortise more than 4 mm. usually indicates a rupture of the anterior talofibular ligament

c. Ankle arthrography: In performing this test you must consider the followingi. The patient must have no allergy to iodineii. The injection should be administered at the anterior-medial aspect ofthe ankle (to prevent confusion from the actual injury)iii. The test must be performed within the first 5-7 days following theinjuryiv. 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 variantd. Peroneal tenography: A diagnostic technique for evaluation of the calcaneo-fibular ligament. 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, a negative test.

7. Differential diagnosis and associated findings:a. 5th metatarsal base fractures (avulsion and Jones) b. Stieda's process fracture (talar posterior process) c. Calcaneal avulsion of the EDB d. Calcaneal anterior process fracture e. Talar dome fractures (medial or lateral) f. Sinus tarsi syndromeg. Peroneal stenosing synovitis h. Peroneal tendon dislocations i. Peroneal neuropathy

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

NOTE* There are certain situations where the stress test may be invalid: genetic ligamentous laxity, history of chronic ankle instability, inability to achieve adequate anesthesia, or inability to properly maneuver the uninjured ankle. In these cases, ankle arthrography would be indicated

NOTE* The main indication for ankle arthrography in a soft tissue injury is to evaluate a possible ankle diastasis and to confirm ligament tears

NOTE* For some patients there is a normal communication between the peroneal tendon sheath and the ankle joint capsule: gives a false positive

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

8. Treatment:a. Symptomatic therapy: Used for patients with negative stress x-rays, patients with a significant medical history which would contraindicate more definitive therapy,. geriatrics with a sedentary lifestyle, and patients who present to treatment 3-4 weeks following injury.i. Elastic compressionii. Iceiii. Analgesicsiv. Weight-bearing to tolerancev. Physical therapy (proprioceptive excercises and strengthening)

b. 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. Surgical treatment 2-3 days following injury (must be young and athletic who need complete stability):

NOTE* TEMPER is an acronym for ankle sprain rehabilitation: T: Timely diagnosis/temporary immobilization E: Edema reductionM: Muscle strengtheningP: Proprioceptive excercisesE: External stabilizing devicesR: Return to activity

8. Inversion injuries can result in the following: a. Sprains of the STJ ligamentsb. Medial STJ subluxationc. Dislocation of the talusd. Osteochondral fractures of the talar domee. Shear fractures of the head of the talus medially f. Shear fractures of the navicular laterallyg. Avulsion fractures of the posterior aspect of the talus h. Avulsion fracture of the base of the 5th metatarsal i. Fracture of the cuboidj. Avulsion fracture of the lateral malleolus

Single ligament rupture:Watson-Jones*: This uses the peroneus brevis, which passes through the fibula from posterior to anterior, through the neck of the talus from dorsal to plantar, back through the fibula, from anterior to posterior, and sutured back onto itself.Lee Procedure (modified Watson-Jones)*: This uses the peroneus brevis tendon, which is then passed through the fibula, from posterior to anterior, and then sutured back onto itself.Evans*: This utilizes the peroneus brevis through an oblique hole through the fibula sutured back onto the belly of the peroneus brevis. StorrenNilsonnePouzetHaigCastaing and MeunierDockery 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, through the calcaneus, backthrough the same drill hole, and tied onto itself, after passing through the neck of the talus.Chrisman and Snook*: This uses the split peroneus brevis, which is passed through the fibula from anterior to posterior through a flap in the calcaneus, and is then sutured back to the peroneus brevis tendon. StrorenHamblyWinfieldGschwend-Francillon

Triple ligament rupture: SpotoffRosendahl and Jansen

9. Complications:a. Inappropriate diagnosis and lack of treatmentb. Early complicationsi. Painful hemarthrosisii. Hematomaiii. Rarely, gangrene of the skin of the lateral ankle in cases of rupture of the perforating peroneal arteryc. Neuropraxia in grades II and III with damage to the intermediate dorsal cutaneous nerve

d.

The most common surgical complication of primary ankle repair, involves the intermediate dorsal cutaneous nerve i. Entrapment neuropathyii. Laceratione. 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 eversionf. Painful sinus tarsi can occur later from an everted ankle position

NOTE* With greater than 20% of stretching, fascicular interruption may occur, causing permanent neurotmesis of the intermediate dorsal cutaneous nerve and producing a profound lateral foot and ankle sensory loss

LIGAMENTOUS INJURIES

Lateral Medial

Common RareAdduction (inversion) Rarely aloneType I (Anterior Talofibular Ligament) palpable tenderness Abduction or External Rotation

Talus Stable - Anterior drawer sign Edema- Inversion stress (occhymosis in deltoid area)- X-Ray (Bilateral)

Deltoid ligament ruptured to variable degree

Treatment 1 strap assesment made as per2 physical therapy Close (1956)

1. Mortise viewType II Anterior Talofibular Ligament Palpable tenderness 2. If lateral displacement of

Calcaneal Fibular Ligament diffuse ankle pain talusIf plantar flexion • possible anterior deltoid ligament 2mm + Type Irupture 3mm + Type II

Talar stability 4mm + Type III+ Anterior drawer Treatment 1. Type I strap- Inversion stress 2. Type II- X-Ray 3. Type III -cast B, K., W. B.

Treatment 1. strap (occ. B. K.. W.B. cast)2. physical therapy3. youth - possible ligament

Type III AnteriorTaloflbular ligament Calcaneofibular ligament Post Deltoid if plantar flexion 1. Talar stability

+ Anterior drawer+ Inversion stress- X-Ray

SyndesmoticTreatment (usually occurs in young athlete) Rare

1. ligament repair with cast Rarely alone2. physical therapy Abduction external rotation

Edemaecchymosis -in syndesmotic area

Anterior + Post Tibiofibular ligament interosseous ligamentusually with Maisonneuve fracture

Treatment 1. Dap. on other assoc injury 2. Mild -cast B.K., W.B. 3. Severe, A.O. Fixation

Deltoid Ligament Ruptures1. Anatomy: The deltoid takes origin off the medial malleolus, which ends structurally in two colliculi (one anterior and one posterior), divided by an intercollicular groove. There is a superficial and a deep deltoid: a. Superficial deltoidi. Naviculotibialii. Calcaneotibial (strongest)iii. Superficial talotibialb. Deep deltoidi. Deep anterior talotibialii. Deep posterior talotibial

2. Mechanism of Injury: Solitary injury to the deltoid is rare, it is usually accompanied by other ligament injuries or fractures.

a. Types

of injuries:i. Supination-external rotation ii. Pronation-external rotation iii. Pronation-abduction

3. Signs and symptoms:a. Pain and swelling on the medial and anterior aspects of the ankleb. Since there are usually associated injuries, the usual presentation is a completely edematous and ecchymotic ankle that is being splinted

4. Diagnosis:a. Scout films (with pronation injuries a high fibular x-ray)b. Stress x-ray (local anesthesia): Can be done by hand or using a Telos®

apparatusi. Mortise view of the ankle where the foot is abducted and everted in relation to the legii. Lateral view where the foot is anteriorly displaced in relation to the leg

5. Treatment:a. Usually closed reduction and with BK NWB cast with the foot in inversion is sufficient for 3-6 weeks, followed by a BK weight-bearing cast for another 3-6 weeks.b. Surgical repair is indicated if closed reduction does not replace the talus to its proper position.

NOTE* Most common are fractures of the fibula and ruptures of the tibiofibular ligaments

NOTE* Stress views are done bilaterally and the clear space is what is compared Note* A clear space of 1 cm. or greater is diagnostic of a complete rupture,

and a displacement of 3mm. or more means tearing of part of the deltoid

Compartment SyndromeUsually diagnosed in the arm and leg, also occurs in the foot, and can follow several types of injuries, most commonly multiple fractures or crushing injuries. This entity should be considered in the differential diagnosis in patients presenting with a painful swollen foot post trauma 1. Definition: Increased compartmental pressure resulting in decreased perfusion and ultimate ischemic changes to the tissues on the compartment. This can eventually result in contractures and poorly functioning limbs,a. Physiology: At rest the intramuscular pressure is approximately 5 mm Hg. During a muscular contracture the pressure can increase up to 150 mm Hg or more. At relaxation, the compartment pressure rapidly drops, and within 5-10 minutes, has returned to baseline. With a compartment syndrome, there is no drop of pressure

2. Types of compartment syndrome:a. Acute: Occurs when the resting pressure in the compartment exceeds the available perfusion pressure. This is usually the result of trauma with hemorrhage or gross muscular edema causing the increased compartmental pressure. If untreated tissue necrosis is inevitable b. Chronic: Occurs when the resting pressure is higher than the normal resting pressure but not so high as to cause hyperprofusion. Following excercise, the time for pressure to return to baseline is protracted. This results in a relative prolongation of the ischemic time resulting in symptoms during or following excercise. Actual muscle necrosis is unusual

3. Diagnosis: Measurement of an increased intramuscular pressure in the compartment via a wicks catheter (usually greater than 30 mm Hg)

4.

Compartments of the foot:a. Medial compartment: Its borders are the medial and lateral intermuscular septum, the medial portion of the plantar aponeurosis, the tarsus (proximally) and shaft of the first metatarsal (distally). It contains the abductor hallucis flexor hallucis brevis, and the FDL tendon

NOTE* This can occur if the deltoid gets rolled up or inverted, or if the posterior tibial tendon gets trapped.

Two criteria must be fulfilled for this diagnosis to be made: a space that is limited by fascia, skin, or bone must be present; 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 presentAny 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

b. Central compartment: Its borders are the medial and lateral intermuscular septum, the central portion of. the plantar aponeurosis, the tarsus (proximally) and interosseous fascia (distally). It contains the flexor digitorum brevis, FDL tendon with lumbricals, quadratus plantae, adductor hallucis, PT and peroneal tendonsc. Lateral compartment: Its borders are the lateral intermuscular septum, lateral portion of the plantar aponeurosis, and the associated osseous components. It contains the abductor digiti minimi, flexor digiti minimi, and opponens digitid. Interosseous compartment: Its borders are the metatarsals and the interossei fascia. It contains the interossei

5. Clinical Findings:a. Pain out of proportion to the clinical findings b. Paresthesiasc. Pulselessnessd. Or none of the above

6. Treatment: a. Fasciotomyi. Double dorsal technique: Midfoot and forefoot: 2 dorsal longitudinal incisions, one over the 2ndmetatarsal and the other over the 4th (deepened down to the metatarsalshaft) where a hemostat is passed into each adjacent interosseous space.The wound is closed secondarily in 5 days. ii. Extensile medial incision iii. Combined approach

7. Associated complications:a. Comminuted fracturesb. Severe soft tissue injuriesc. Post-ischemia swellingd. Intramuscular hematomas associated with bleeding diasthesis e. Crush injuries

Open Fracture Classification System andTreatment1. Gustillo and Anderson described an open fracture classification system:This depends upon the mechanism of injury, degree of soft tissue damage,the configuration of the fracture, and the level of contaminationa. Type 1:i. Wound less than 1 cm long and cleanii. Minor soft tissue damage is presentii. Fracture is simple, transverse, or short oblique with minimalcomminutionb. Type 2:i. Wound more than 1 cm. long without extensive tissue damage, flapsor avulsions

ii. There is a slight crushing injury, moderate comminution of the fracture ill. Moderate contaminationc. Type 3: Extensive soft tissue damage, including muscles, skin, and neurovascular structures, with a high degree of contamination (high velocity injuries, farm injuries)i. Type 3A: Open fractures with adequate soft tissue coverage of bone despite extensive soft tissue lacerationii. Type 3B: Open fractures having extensive soft tissue loss with periosteal stripping and bone exposure. Severe contamination and severe comminution. Usually a local or free flap is needed for bony coverageiii. Type 3C: Open fractures are associated with arterial injury requiring microvascular repair, regardless of the soft tissue coverage

2. General principles of treatment:a. Tetanus history and therapy administeredb. Thorough H & P conducted (blood loss measured-CBC,HCT, Hb) with neurological, musculoskeletal, and vascular assessment of the lower extremitiesc. Complete x-raysd. Appropriate antibiosis should be administered in the E.R. (cultures and gram stains should be taken)

e. Immediate debridement and irrigation, with repeat debridement and irrigation in 24-48 hours

f. All

foreign debris should be excisedg. All marginal, macerated skin, and soft tissue should be debridedh. Fluorescein (non-toxic dye) may be used to assess the viability of the soft tissue structuresi. The wound should be kept moist and re-evaluated in 48-72 hours, with repeated debridements, especially if soft tissue coverage is necessary

NOTE* The primary bacteria encountered in open fractures is Staph. aureus. However, the choice of antibiotic is determined by the extent of the soft tissue injury. 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). For type 3 injuries a cephalosporin plus an aminoglycoside (1.5 gm/kg body weight then 3 to 5 gm/kg body weight in divided doses) is used. Penicillin is added for farm injuries to cover Clostridium sp.

NOTE* The irrigant can contain either 1 gm cefazolin in 1 liter of sterile saline, or 50,000 units of bacitracin and 1 million units of polymyxin B in 1 liter of sterile saline.

j. For type 1, 2, and 3A open fractures delayed primary closure, using skin grafts within 5-7 daysk. For type 3B and 3C open fractures, 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. External fixation should be used for all type 3 and unstable type 2 fractures

m. Internal fixation (screws, plates, pins, etc.) should be used for articular and metaphyseal open fractures. This is done preferably within 8 hours of the

injury

3. Absolute indications for open reduction:a. Irreducible fractures where function and alignment can not be obtained otherwiseb. Displaced intra-articular fractures where incongruity will lead to degeneration of the jointc. Displaced epiphyseal fractures with a large potential for growth disturbanced. Major avulsion fractures with muscle ligament attachmentse. Nonunions that do not have the capacity to unite (pseudoarthrosis and avascular nonunions

4. Antibiotic considerations:a. Limiting the duration of the initial antibiotic therapy is important to minimize the emergence of resistant nosocomial bacteriab. Type 1 fractures are treated with Cefazolin 2 gm STAT followed by 2 gm Q 8 h for 48 to 72 hoursc. Type 2 and 3 are treated with combined therapy, using cefazolin as above, plus an aminoglycoside (Gentamycin or Tobramycin) dosed at 1.51.7 mg per kg on admission, followed by 3.0 to 5.0 mg per kg per day in divided doses. The duration of therapy is 3 days unless overt infection developsd. Administer 10 million units of Pen G if the injury was sustained on a farm, to cover for Clostridium sp.

NOTE* 10-15 mg/kg of fluorescein is injected IV and observed under UV light after 10-20 minutes. Vascularized tissue will fluoresce yellow-green and nonvascularized tissue will appear dark blue

The advantages of external fixators include the ease of application without additional trauma, allows for daily wound inspections and care, allows for grafting procedures, accomplishes compression/reduction of the angulation/ stabilization of the fracture without much surgical trauma

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

Soft Tissue Injuries1. Classification:a. Tidy wound: Surgical incision, lacerationb. Untidy wound: Crush, avulsion, abrasionc. Wound with tissue loss: Excision, burn, ulcer, avulsiond. Infected wound: Established (cellulitis, lymphangitis, abscess, bum, or vasculitis) or Incipient (bum, contaminated wound, abrasion)

2. Treatment (general):a. Tetanus prophylaxisb. Antibiotic prophylaxisc. H 8 P, including vascular, neurological, musculoskeletal and integumentary statusd. Inspection of the wound under local or regional anesthesiae. Initial gentle cleansing of the wound with a mild soap (no strong antiseptics that can cause tissue damage) f. X-rays, CBC, and urinalysis as necessaryg. Primary wound care: remove all foreign and devitalized materialcopious flushing, atraumatic tissue handling, avoid tourniquet h. Skin closure when appropriate

3. Treatment (specific):a. Tidy wound: Once debrided, can be closed after appropriate skin cleansing (skin edges may be freshened)b. 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. Secondary or delayed primary closure may be indicated. Swelling within closed compartments may indicate the need for the release of damaged fascia or skinc. Wound with tissue loss: Must prevent the wound from drying out and must cover exposed vital structures using biological dressings, porcine xenografts, or appropriate autograftf. Infected wound: Prior to closure the wound must be debrided and converted to a contaminated wound, and then a clean wound (check with C&S and colony counts: less than 105 bacteria per millimeter meanscontamination)

Crush Gunshot and Lawnmower Injuries1. General protocols:a. Priority is given to prevention of infection especially Clostridia sp.b. Therefore tetanus prophylaxis is given (see chapter Infectious Disease) c. Antibiotic therapy is started after cultures are taken d. Debridement and copious lavage under local/regional, or general anesthesiae. 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. The wound is reexamined under regional/general anesthesia in 24-48

hours, and after further debridement the wound is packed open g. The wound should not be closed before 5-7 days (check cultures and use clinical judgement)

h. Use xenograft as necessary to prevent further contaminationi. 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. Rigid stabilization of fractures

Puncture Wounds

1. General protocols:a. Tetanus prophylaxisb. Remove all foreign material, leave wound open, do C&S c. Start broad spectrum antibiotics d. If no improvement in 3 days suspect a gram (-) infectione. If bone or joint is penetrated or if wound is deep, surgical explorationand debridement are necessaryf. If pain persists after 4 days of treatment use bone/gallium scans, sed rate,WBC to follow patient progress

Epiphyseal Plate Injuries: Also see section: Pediatrics(Pediatric Fractures)1. Anatomic differences: Since the growth plate is radiolucent, acute injury can only be inferred from widening of the growth plate or from displacement of the adjacent bones on plain x-ray. The periosteum is stronger, thicker, and produces callus more quickly than in adults

2. Biomechanical differences: Pediatric bone is less dense, more porous with a smaller lamellar content than adult bone. It also will fail not only in tension, as adult bone, but in compression as well. Hence there are certain pediatric fracture patterns: buckle fractures, plastic deformation of bone, and greenstick fractures

3. Physiological differences: Growth provides the basis for a greater

NOTE* The most important criterion is the clinical appearance of the wound in the decision to close a wound. The number 105 bacteria present in the wound is mentioned as a criteria of active infection, as it has been seen on the board exams (this is unreliable)

These wounds deserve special attention because they characteristically have a benign presentation that can rapidly progress to OM if not treated appropriately. Complications run as high as 10%. Pseudomonas is the most common pathogen isolated

degree of remodeling than is possible with the adult (a bump of a malunion is corrected by periosteal resorption; a concavity is filled out by periosteal new bone). This is an example of Wolff's Law. Also, a fracture through the shaft of long bone stimulates longitudinal growth (increased nutrition of the growth cartilage), which can result in a longer bone as a result of a fracture. Because of this, pediatric fractures can be treated more conservatively than with an adult

4. Growth plate injuries: Problems after injury are rare, but when growth is disturbed, the reason is from avascular necrosis of the plate, crushing orinfection of the plate, formation of a bone callus bridge between the bony epiphysis and metaphysis, and hyperemia producing local overgrowth. There are 2 types of growth plates, epiphyseal (those that form under pressure) and apophyseal (those that form under traction)

5. Anatomy: The growth plate is a cartilagenous disc situated between the epiphysis and the metaphysis. The germinal cells are attached to the epiphysis and their blood supply is from the epiphyseal vessels. As the germinal cells multiply, the cell population of the plate increases. The plane" of separation in the physis is most frequently at the junction of the calcified and uncalcified cartilage, known as the zone of transformation. With an epiphyseal separation, most of the important germinal part of the plate usually remains with the epiphysis. If much of the germinal layer is disturbed, growth may be affected

6. Classification: Salter-Harrisa. Type 1: A complete separation of the growth plate at the zone of transformation, no disruption of growth, treated with closed reduction and immobilization for 3 weeksb. Type 2: Separation of the growth plate with extention of the fracture line into the metaphysis. This extension creates the 'Thurston Holland Sign'. There is usually no growth disturbance and it is treated the same way as type 1c. Type 3: Separation of the growth plate with extension of the fracture line into the epiphysis so that it is intraarticular. Potential for growth disturbance as the fracture line crosses the entire growth plate, and must not be left displaced by ORIFd. Type 4: A fracture from the metaphysis through the growth plate and into the epiphysis, and can result in growth disturbance. This fracture is unstable and requires ORIFe. Type 5: A crush type injury usually with subsequent growth disturbance. Treated with closed reduction (if displaced) and immobilization 3-6 weeks NWBf. Type 6: A scooping out of a portion of the growth plate, via some type of projectile causing osseous and soft tissue damage. Any large fragmentsof bone are reduced. Bony bridging causing growth disturbances can be acomplication here. Treat the bony bridge with resection and interposition of fat or silicone rubber

g. Type 7: An intraarticular fracture that does not involve the physis. Very difficult to diagnosis in the very young. 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. Apophyseal Injuries: Either an inflammatory process secondary to traction vs. a Salter-Harris fracture type 1a. Calcaneal apophysitis: Involves reduction of stress to the apophysis, (heel lifts, orthoses, and local anti-inflammatory measures) with severe cases requiring BK casting. Later calf muscle stretching is helpfulb. Tuberosity of 5th metatarsal: Injury from direct impact or forced inversion of the foot. If the tuberosity is displaced, closed reduction with immobilization for 3 weeks

8. Treatment: Always advise of the long term sequelae of the fracture

9. 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. Never use threaded pins or screws across a growth plate

10. Specific ankle fractures:a. Tillaux fracture: A Salter-Harris type 3 of the tibia involving the lateral aspect of the tibia. This fracture is unique to the age group of 12-13 year olds. Treatment is ORIF if displaced or unstable, and closed reduction with immobilization for 6 weeks if stable and in anatomic alignmentb. Triplane: A Salter-Harris type 4 fracture of the tibia. Diagnosis is made by visualizing the fracture on at least 2 views. An unstable fracture, requiring ORIF

Digital Fractures and Dislocations1. Fractures of the hallux:a. Communited fracture of the distal phalangeal tuft i. Mechanism: Direct traumaii. Treatment: Local anesthesia and prep Avulse the nail atraumatically

If closed fracture reduce any gross prominences, replace nail plate as part of compression dressing, patient instructed to check vascular status frequently, Reece© shoe, ice packsIf open fracture, tetanus prophylaxis, IV antibiotics, debride necrotic tissue and loose exposed bone leaving no prominences, irrigate copiously, open drainage, Reece©

shoe, and follow appropriately

b. Intra-articular dorsal avulsion fracture of the distal phalangeal base:i. Mechanism: Forced plantarflexion of the hallux IPJ (stubbing) resulting in avulsion of the EHL insertion

ii. Treatment of displaced fracture (most common): ORIF followed byReece© shoeiii. Treatment of nondisplaced (uncommon): Closed reduction with slipper cast, or BK cast (with or without percutaneous pinning)

c. Hallux IPJ intra-articular fractures of the distal or proximal phalanx:i. 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 phalanxii. Treatment of displaced fracture (most common): First attempt closedreduction, and if successful pad 1st interspace with felt or cotton and tapeto the 2nd toe. If closed reduction fails, ORIF larger fragments and excise smaller fragments. Reese© shoe for 4-6 weeks

d. Proximal phalanx shaft fracture:i. Mechanism: Direct or indirect trauma resulting in a transverse oblique fractureii. Treatment of displaced fracture: Closed reduction (with or withoutpercutaneous pinning), splinting, Reese© shoeiii. Treatment of nondisplaced fracture: Buddy splinting to 2nd toe andReece© shoe

e. First MPJ intra-articular condylar fractures of the proximal phalanx: i. Mechanism: Transverse plane torque resulting in avulsion of the insertion of the medial or lateral intrinsicsii. Treatment of displaced fracture: ORIF followed by Reece© shoe for 6 weeks(smaller fragments maybe excised and the intrinsics reinserted)iii. Treatment of nondisplaced: If no change in hallux abductus, then buddy splint to the 2nd toe, if the hallux abductus changed, consider surgical repair.

2. Fractures of the lesser toes:a. Fractures of the distal and intermediate phalanges: Rare unless crush type

b. Non-articular proximal phalangeal fractures:i. Mechanism: Direct or indirect trauma (stubbing most common) resulting in a transverse, oblique or spiral fracture appearing sub-capitally, mid-shaft, or at the base or epiphysisii. Treatment of displaced fracture (less common): Closed reduction followed by buddy splinting, or ORIF for gross reduction failuresiii. Treatment of nondisplaced fractures (common): Buddy splinting

c. PIPJ intra-articular proximal phalangeal fractures:i. Mechanism: Usually a stubbing injury with axial forces resulting in an oblique push off or comminuted fractureii. Treatment of displaced and non-displaced fractures: Closed reduction aimed at restoring alignment, followed by buddy splinting. If failure then primary arthroplasty.

d. MPJ intra-articular proximal phalangeal fractures: i. Mechanism: Usually a stubbing injuryii. Treatment of displaced fracture: ORIF depending on the size of the fragment and comminutioniii. Treatment of nondisplaced fracture: Reece© shoe for 6 weeks

1st MPJ Trauma1. Turf Toe:a. Mechanism: Hyperdorsiflexion, hyperplantarflexion, hyperadduction, or hyperabduction stress resulting in a - 1st MTPJ sprain without alignment changesb. X-ray evaluation: Rule out dislocation, osteochondral injury, or sesamoid fracture (take MO, LO, Lateral, AP, plantar axial)c. Treatment: Ice, rest, Reece© shoe, modify the athletic shoe.

2. First MTPJ dislocation:a. Mechanism: Hyperdorsiflexionb. X-ray evaluation: Rule out osteochondral fracture and sesamoid fracture(take AP, lateral, plantar axial) c. Classification (Jahss): i. Type 1: Joint capsule torn transversely under the metatarsal neck Proximal phalanx, plantar capsule, and sesamoids dislocated dorsally on

the first metatarsal head First metatarsal protrudes through the capsule, depressed plantarly by the

retrograde forces of the hallux Hallux IPJ is flexed Usually not reducible by closed techniqueii. Type 2A: Same as type 1 except that rather than the entire plantar capsule and

sesamoid apparatus dislocated dorsally, the intersesamoidal ligament ruptures and the sesamoids sublux to each side of the metatarsal head

Easier to reduce than type 1 iii. Type 2B: Same as type 2A except sesamoid fractures occur instead of the

intermetatarsal ligament rupturing Easier to reduce than type 1

3. Treatment:a. Type 1: Open reduction

b. Type 2A: Closed reduction followed by Reece shoe or BK walking cast c. 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. Sesamoid fractures:a. Mechanism: Fall from a height, repetitive direct trauma (dancing), and repetitive indirect trauma (traction of the intrinsics)b. Presentation:i. Sesamoid involved: Tibial more than fibular (tibial is larger), rarely both injuried, almost never bilateralii. Clinical presentation: Pain on direct palpation and pain on hallux dorsiflexioniii. Differential diagnosis of pain in the sesamoid area: Joplins neuroma, sesamoiditis, osteochondritis dissecans, osteochondrosis, ruptured bipartite sesamoid, turf toe, DJD/eroded crista, hypertrophic sesamoid, and fractured sesamoidc. X-ray evaluation: Order bilateral AP, lateral and plantar axial (MO for tibial and LO for fibular sesamoid) 75% of bipartite sesamoids are unilateral. Bone scan if in doubtd. Normal sesamoids: Ossification appears at 8-10 years Bipartite sesamoids more common in tibial than in fibular Sesamoids may be multipartite

Nail Bed Trauma1. Classification (S. Malay):a. Primary onycholysis:i. A separation of the nail plate from the bedii. Partial avulsions cause posterior nail fold friction injury, subungualbleeding, and digital sepsis especially in compromised patients iii. Removal of the nail plate, antisepsis, and antibiotics (prn) iv. No adverse sequelaeb. Subungual hematoma:i. Blood clot under the nail plateii. Must check for fractures of the plate from impactioniii. Treat like open fractures, the nail plate must be removed from the tissue to decompress the areaiv. X-rays should be taken to r/o fracturev. The nail plate can be removed if the hematoma comprises more than 25% of the nail platevi. Drill holes can be made if feasible c. Simple nail. bed laceration:i. Tetanus coverage

NOTE* Closed reduction can be tried under anesthesia as follows: traction and increase dorsiflexion, then push the proximal phalanx into contact with the metatarsal head, then push (don't pull) the proximal phalanx into the reduced position, maintaining contact with the metatarsal head

ii. Systemic antibioticsiii. Surgical cleansing and lavage (no epinephrine utilized in seriously traumatized digits)iv. If you are avulsing a salvagable nail plate, remove it in one piece and save for subsequent splintingv. Nail bed injuries are usually repaired with a 6-0 absorbable suture on an atraumatic needlevi. The root and the bed must be accurately aligned on the toevii. Periosteal irregularities must be debridedviii. Reusing the nail plate involves scraping all soft tissue from the nail plate, drilling holes through the body, then soaked in Betadine until the bed repair is accomplished, and then the nail plate is replaced on the nail bed and anchored with Steri-strips®ix. Avulsive lacerations of the bed are treated with intermediate thickness skin graftd. Complex nail bed laceration: As above plusi. If a major segment of the proximal nail fold over the matrix is avulsed with a skin defect, rotational flaps are utilized

e. Nail bed laceration with phalangeal fracture: As above plus i. Subungual fractures must be accurately reduced ii. Remove all bone spicules and nail fragments

2. Complications:a. Split nailb. Adhesions of the skin fold to the nail root c. Chronic ingrown nails d. Widening of the nail e. Narrowing of the nail f. Protruding or non-adherent nail g. Malaligned nail

Toe Tip Injuries With Tissue LossThese injuries are secondary to crush forces, and should be considered andtreated like open fractures. Tissue loss increases the likelihood of poorcosmetic result1. Classification (Rosenthal): According to the level and direction of tissuelossa. Level of nail bed tissue lossi. Zone 1: distal to bony phalanx ii. Zone 2: distal to the lunulaiii. Zone 3: proximal to the distal end of the lunulab. Direction of tissue loss i. Dorsal obliqueii. Transverse guillotine iii. Plantar obliqueiv. Tibial or fibular axial

v. Central or gouging

2. Treatment:a. Zone 1:i. Flush, debridment and appropriate wound closure (usually secondaryintention)ii. Occasionally skin graft large defects (split thickness less durable, fullthickness more durable)b. Zone 2:i. Reduction of bone with debridement of necrotic tissueii. Coverage of nail bed and phalanx tip usually achieved by localneurovascular advancement flapc. Zone 3:i. Not suitable to initial treatment in ER or officeii. Usually complete nail bed lossiii. OR debridement of necrotic tissue and matrix iv. Delayed revision of the digit v. Attempt to maintain tendon function v. Terminal Symes may be necessary

Dog and Cat BitesBoth dog and cat bites are susceptible to infection because of direct inoculation of bacteria from the animals into the bite wound. In addition to tearing of tissue, dogs can also cause a crushing injury. Most patients with bite wounds harbor bacteria, so that aggressive therapy should be undertaken initially.1. Pasturella multocida (gram negative bacillus) is present in 50% of cat bites and 25% of dog bites Other organisms should also be considered: Pseudomonas, Staphylococcus, and beta streptococcus

2. 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. X-rays of the involved area should be obtained

4. Thorough and aggressive debridement and irrigation (manual lavage using Ringer's lactate or dilute Betadine®)

5. Elevation and immobilization with the ankle at 900, and after 72 hours improvement occurs, then initiate ROM and adjunctive PT

6. Leave any potentially contaminated wound open for 4-6 days, and at that time, if the wound is clean, without redness or swelling, it is reasonably safe to perform primary closure

7. The use of prophylactic antibiotics is still controversiala. For cat bites, dicloxicillin, penicillin, or Augmentin® is recommended

(erythromycin in penicillin allergy)b. For dog bites dicloxicillin, cephalexin, or Augmentin® is adequate (one study showed a 95% cure of infected dog bites with cephadrine)

8. Rabies is of concern with any animal bite. See Chapter 6, Infectious Disease, section on Rabies