Embed Size (px)
Citation preview
Foot and Ankle Trauma
Brian J Burgess, DPM, AACFAS Hinsdale Orthopaedic Assoc. Midwest Podiatry Conference
April 20, 2013
Brian J Burgess, DPM, AACFAS
• Associate of Hinsdale Orthopaedics.
• Doctor of Podiatric Medicine.
• Board Qualified by the American Board of Podiatric Surgeons (ABPS).
– Foot Surgery.
– Rearfoot Reconstruction and Ankle Surgery.
Topics
• Soft Tissue Trauma
• Toe Fracture
• Jones Fracture
• LisFranc Dislocation
• Calcaneal Fractures
• Ankle Fracture Dislocation
SOFT TISSUE TRAUMA
Soft Tissue Trauma
• 62 yo male.
• Motorcycle crush injury.
• Exhaust on foot for several minutes.
Soft Tissue Trauma metatarsal fracture
• Open 2nd metatarsal fracture.
• Moderate displacement and angulation.
• Unable to ORIF due to soft tissue trauma.
Soft Tissue Trauma two weeks since injury
Soft Tissue Trauma incision and drainage
Soft Tissue Trauma four months s/p skin graft
Soft Tissue Trauma four months since injury
Take Home Points soft tissue trauma
• Must really respect the soft tissue.
• Unique and difficult problems in initial management, reconstruction, and attainment of long-term functional results.
Toe Fracture Dislocation
Toe Fracture/Dislocation
• 9 yo female patient.
• Kicked a chair.
• Immediate pain and deformity to her 4th toe.
• ED
Toe Fracture/Dislocation
• 9 yo female patient.
• Kicked a chair.
• Immediate pain and deformity to her 4th toe.
• ED
Toe Fracture/Dislocation post reduction XR
• Closed reduction failed.
• Significant displacement.
• 9 yo.
• Decided to close reduce with pin fixation in OR.
Toe Fracture/Dislocation two weeks post-op
Toe Fracture/Dislocation two weeks post-op
Toe Fracture/Dislocation six weeks post-op
Bone callous
Toe Fracture/Dislocation six weeks post-op
Take Home Points toe fracture
• Most common fracture of foot.
• Proximal phalanx. • Can accept moderate displacement.
• Most can be treated by buddy splint
and ambulating in stiff-soled shoe.
Jones Fracture
Jones Fracture initial presentation
• 28 yo healthy male.
• Work-related right foot fracture.
• X-rays confirmed a true Jones Fracture.
Jones Fracture anatomy
• An acute fracture occurring in the proximal portion of the fifth metatarsal base at the metaphyseal-diaphyseal junction.
• Approximately 18 mm from the joint.
Jones Fracture metaphyseal-diaphyseal junction
Jones Fracture metaphyseal-diaphyseal junction
JONES NO! NO! NO!
Jones Fracture treatment options
• Conservative – NWB 6-12 weeks. – 25% non-union rate. – 33% re-fracture rate. – “It is going to take a long time to heal, it may not heal, and if it does
heal, it may re-fracture”.
• IM screw fixation
– Stab incision closed with steri-strip. – NWB x 2 weeks. – WBAT in pneumatic walking boot, ROM. – Gym shoe at 4-6 weeks. – Quicker return to work, no calf atrophy or cast disease, minimal risk of
nonunion, minimal risk of re-fracture.
Jones Fracture ORIF guide wire placement
Jones Fracture ORIF screw tap
Jones Fracture ORIF measure
Jones Fracture ORIF intra-op fluoroscopy
Jones Fracture ORIF incision
Take Home Points jones fracture
• 50% of Jones Fractures treated conservatively will either go on to nonunion or will re-fracture.
• ORIF – Quicker recovery and return to work. – Significantly decrease chance of non-union or re-
fracture. – Improves patient’s quality of life. – Everyone is happy.
LisFranc Fracture Dislocation
LisFranc Fracture/Dislocation
• 46 yo male.
• Fell down a flight of stairs.
• Presented to the ED with severe foot pain/swelling.
LisFranc Fracture/Dislocation
• Can not tolerate any displacement.
• Collapsed foot structure.
• Decided to perform ORIF once swelling decreased.
LisFranc Fracture/Dislocation two weeks post-op
LisFranc Fracture/Dislocation two weeks post-op
LisFranc Fracture/Dislocation percutaneous k-wire fixation
LisFranc Fracture/Dislocation three months post-op
LisFranc Fracture/Dislocation three months post-op
LisFranc Fracture/Dislocation three months post-op
Take Home Points lisfranc fractures
• Commonly missed on initial XR.
• Can not accept any amount of displacement.
• Almost all require ORIF.
• Pain, stiffness and post-traumatic arthritis of midfoot very common.
Calcaneal Fracture
• 54 yo male.
• Fall from a two-story building.
• Unable to place weight on Left Heel.
• Ambulance to ED.
Calcaneal Fracture initial radiographs
Calcaneal Fracture CT scan
Calcaneal Fracture fracture lines
Calcaneal Fracture 3D CT reconstruction
• Concomitant lumbar spine fractures.
• 10-20% of the time.
• Compression fracture of T12-L2.
Calcaneal Fracture concomitant injuries
Calcaneal Fracture surgical planning
• Immediate surgery through minimal incision approach.
• Delay 10-14 days for traditional lateral approach.
• Wound complications!!
Calcaneal Fracture incision placement
Calcaneal Fracture intra-operative view
Calcaneal Fracture three months post-op
Calcaneal Fracture incision at three months
Take Home Points calcaneal fracture
• 75% fall from a height.
• Most have associated injuries.
• Soft tissue complications are common.
• ORIF if articular involvement and joint depression.
Ankle Fracture Dislocation
• 48 yo male with ETOH abuse.
• Tripped over extension cord.
• Ambulance to ED.
• Obvious ankle pain and deformity.
Ankle Fracture/Dislocation clinical presentation
Ankle Fracture/Dislocation initial radiographs
• Can generally tolerate 2mm of displacement.
• 16mm.
• Unstable fracture – Fibula fractures – Delotid ligament ruptured
• Needs ORIF if surgical
candidate.
Ankle Fracture/Dislocation displacement
Ankle Fracture/Dislocation closed reduction
Ankle Fracture/Dislocation six weeks post-op
• Goal of surgery is to restore the normal anatomy of the ankle mortise.
Ankle Fracture/Dislocation
• Open ankle fracture is EMERGENCY!
Ankle Fracture/Dislocation
Take Home Points ankle fracture
• Cast immobilization x 6 weeks if < 2 mm
of displacement.
• ORIF if > 2 mm displacement.
• If more than 1 fracture or ligament injury, it is likely unstable and requires ORIF.
