Fractures and Dislocations

HINDFOOT Talar fractures are uncommon. Minor avulsion fractures of the neck, body, and lateral process are usually treated with a posterior slab, crutches, and orthopedic follow-up. Os trigonum and transchondral talar dome fractures are difficult to identify in the ED and are sometimes diagnosed in the follow-up of "ankle sprains." Major fractures of the talar neck and body are associated with severe dorsiflexion and axial forces. These injuries often require open reduction and merit immediate orthopedic consultation. These fractures are frequently complicated by avascular necrosis.

Peritalar or subtalar dislocations are rare. In this injury, the calcaneotalar and talonavicular joints are disrupted while the tibiotalar joint remains intact. Although the dislocation can occur in any direction, medial dislocation is by far the most common and is the result of a severe rotational-inversion force. These injuries require immediate orthopedic consultation and emergent reduction. Closed reduction can sometimes be accomplished using conscious sedation in the ED, although frequently a general or regional anaesthetic in the operating room is required.

An axial load to the heel, caused by a fall from a height, is the mechanism associated with most fractures of the calcaneum. These injuries are frequently associated with other injuries, most commonly vertebral column, forearm, and other lower extremity fractures. Fractures should be categorized as intraarticular or extraarticular.

Although the more common subtalar, intraarticular fractures are usually obvious on the lateral foot radiograph, some compression fractures may be subtle. When this injury is suspected by mechanism or examination, carefully examine the radiograph utilizing the measurement of Boehler's angle. If the angle is less than 20°, suspect a fracture (Fig 2.§.9-3). The criterion for open reduction of these fractures is controversial, with CT scanning playing an important diagnostic and preoperative planning role. Seek immediate orthopedic consultation. In the interim, apply a well-padded posterior splint, elevate the foot, and address analgesic needs.

Comminuted fractures of the calcaneum can be extremely painful. The incidence of compartment syndrome with these fractures is high.

FIG. 269-3. Boehler's angle is formed by two lines, one between the posterior tuberosity (A) and the apex of the posterior facet (B), and the other between the apex of the posterior facet (B) and the apex of the anterior process (C). An angle less than 20 degrees suggests a calcaneal compression fracture.

Extraarticular fractures are less common and usually are associated with a rotational mechanism as well as an axial load. Included are fractures of the tuberosity, the sustentaculum tali, anterior process avulsion, and extraarticular oblique body fractures. Most nondisplaced fractures can be treated conservatively with a posterior slab, crutches, and early orthopedic consultation.

MIDFOOT Isolated fractures of the navicular, cuboid, and cuneiforms are uncommon and are difficult to identify on radiograph. Fractures of the navicular are most common and can involve the tuberosity, the dorsal surface, and the body. Isolated fractures of the cuboid and cuneiforms are extremely rare, and an associated injury to the Lisfranc joint should be sought. Most isolated injuries of the tarsal bones are treated conservatively.

The six-bone tarsometatarsal complex is known as the Lisfranc joint. Injuries to this joint are not uncommon, and unfortunately up to 20 percent of these injuries are missed in the ED.6 The force required and the mechanism of injury are varied and can range from a seemingly minor rotational force to severe axial load as seen in an automobile accident. The great majority of injuries to the Lisfranc joint are associated with fractures, usually of the metatarsals, the cuboid, or the cuneiforms. A fracture of the base of the second metatarsal is pathognomonic of a disruption of the ligamentous complex ( Fig...269-4). The Lisfranc injury is classified by the direction of the dislocation. A divergent dislocation describes metatarsals splayed in both medial and lateral directions, usually between the first and second metatarsals. In isolated dislocations, one or more metatarsals are displaced from the rest. In homolateral dislocations, all five metatarsals are displaced in the same direction, either laterally or medially. Suspect this injury if there is point tenderness over the midfoot or when there is laxity between the first and second metatarsals in a dorsal-plantar direction. Diagnosis is made radiographically on the AP view when there is more then a 1-mm gap between the bases of the first and second metatarsals. Weight-bearing radiographs may be required to make the diagnosis. Injuries to the Lisfranc joint frequently require open reduction and fixation or percutaneous placement of Kirschner wires and non-weight-bearing for several weeks. These injuries are complicated by pedal artery damage in the short term and degenerative arthritis and chronic pain in the long term.

FIG. 269-4. Fracture of the base of the second metatarsal.

FOREFOOT Metatarsal fractures are most often associated with a crush or more occasionally with a twisting injury. Metatarsal fractures are divided into shaft and neck fractures. Nondisplaced shaft injuries are usually treated conservatively with either a walking cast or an orthopedic shoe. An exception is a fracture of the first metatarsal shaft. Keep this injury non-weight-bearing. Likewise, displaced shaft fractures of the middle metatarsals can be treated with closed reduction, followed by immobilization in a cast and non-weight-bearing for 6 weeks. A displaced first metatarsal fracture will often require an open reduction and fixation. Metatarsal neck fractures generally follow the treatment of shaft fractures, but postreduction instability of displaced neck fractures is not uncommon and open fixation is sometimes required.

Fifth metatarsal fractures are the most common of the metatarsal fractures. Shaft fractures usually can be treated conservatively, as above. The Jones fracture is described as a transverse fracture through the base of the fifth metatarsal 15 to 31 mm distal to the proximal part of the metatarsal. This fracture is frequently complicated by nonunion or malunion and should be treated with a non-weight-bearing cast for 6 weeks. The "pseudo-Jones" is an avulsion fracture of the tuberosity of the base and can be treated with a cast shoe. (Fig..i.269-5).

FIG. 269-5. Fractures of the fifth metatarsal.

Most nondisplaced phalangeal fractures can be treated conservatively with "buddy taping" and, occasionally, a cast shoe. Address the patient's analgesic need and arrange orthopedic consultation on a prn basis. Advise against prolonged ambulation or standing in the first week. Displaced fractures can be manipulated into position by using a digital block and manual traction. Some authors advocate open reduction of some displaced fractures, especially of the big toe.

Most dislocations of the forefoot involve the the distal interphalangeal and posterior interphalangeal joints of the second through fifth toes. These injuries can be

FIG. 269-4. Fracture of the base of the second metatarsal.

FIG. 269-5. Fractures of the fifth metatarsal.

easily reduced by manual traction and treated with buddy taping as needed. Dislocations of the big toe are rare, occasionally difficult to reduce, and require walking-cast immobilization for 3 weeks.

OPEN FRACTURES Open fractures of the foot require immediate orthopedic consultation. In the interim, protect open fractures from further contamination by applying a wet, sterile dressing over the wound with a gauze roll. Splint the injury until definitive treatment is available. Consider tetanus immunoglobulin if the wound is grossly contaminated. The antibiotic of choice is cephalexin, and add an aminoglycoside if the wound is grossly contaminated. Consider clindamycin for patients with a penicillin allergy. If there is going to be a significant delay to operative management, the wound should be irrigated.

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