Chapter 62: Fractures and Dislocations of the Midfoot and Forefoot

Thomas A. Schildhauer, Marlon O. Coulibaly, Martin F. Hoffmann

Chapter Outline

Introduction

The modern understanding of the evolutionary anatomy of the human foot comprises features such as (1) a long Achilles tendon to reduce stress and improve energy efficiency; (2) a passively stabilized longitudinal plantar arch to improve shock absorption and plantar flexion; (3) an enlarged calcaneal tuberosity for stress reduction, (4) a close-packed positioning of the calcaneo-cuboidal joint to improve spring effectiveness of the plantar arch during running; (5) the permanent inability to oppose the hallux to increase stability during plantar flexion; and (6) relatively short phalanges adding to improved lever function.45 
Based on the functional anatomy of the foot two segments comprising the longitudinal arch have been described.302 These distinct segments are the medial column of the foot (calcaneus, talus, tarsal navicular, cuneiform 1 to 3, and metatarsal 1 to 3) and the lateral column of the foot (calcaneus, cuboid, and metatarsals 4 and 5). In the midsection of the foot an incomplete transverse arch has been described. Within this arch tensile forces are eliminated and converted into compressive forces. Although foot injuries are not life threatening, they have significant impact on the activity of daily living of the patient.276 Therefore our goal is to give an intense overview of mid and forefoot fractures and a step-by-step approach to forefoot, midfoot, and tarsal reconstruction. 

Injuries of the Midfoot

The midfoot is anatomically defined as the section between the Chopart joint line and the Lisfranc joint line. The two French surgeons defined these joint lines originally not for traumatic foot reconstruction but as amputation lines. Injuries that involve the midfoot are rare and comprise only about 5% of all foot injuries.130,135,175,289,332,364 Overall, an incidence of 0.45% has been reported with 5.0 injuries per 100,000 population and unimodal distribution affecting younger men and women.76 This is due to a strong ligamentous connection between the five bones forming the midtarsal complex (the navicular, the cuboid and the medial, middle and lateral cuneiforms). Two anatomical and functional units can be distinguished: The medial column with the tarsal navicular bone as the supporting structure and the lateral column with the cuboid bone as the keystone.142,179,283 Furthermore, the cuneiforms form with the cuboid the transverse arch of the foot.179 The majority of midfoot injuries are combined injuries of osseous and ligamentous structures. Isolated osseous injuries in this region are rare and have to be carefully evaluated in order not to miss an associated ligamentous injury. Up to 30% of midfoot injuries are missed primarily or treated in a delayed manner.126,266,276 This is important since missed or secondarily diagnosed osseo-ligamentous midfoot injuries have an overall poorer outcome compared to acutely treated injuries.266,288,366 The types of injury mechanisms are equally divided between high- and low-energy trauma.225 
The rigid anatomic construct of the five midfoot bones is placed in between the hindfoot and the forefoot as a static connection to build the osseous transverse and longitudinal arches of the foot. The Chopart and the Lisfranc joints have strong ligaments interconnecting the midfoot bones (Fig. 62-1). Due to the repetitive loading that occurs during gait, the plantar ligaments are stronger compared to the dorsal ligaments. Laterally, the bifurcate ligament connects the anterior calcaneal process to the cuboid and to the lateral border of the navicular. On the medial side the plantar calcaneonavicular, or spring ligament, the dorsal talo-navicular, and the medial calcaneonavicular ligament are the major structures. The only tendon that inserts entirely in the midfoot is the tibialis posterior tendon. The plantar insertion of the tibialis posterior tendon connects all midfoot bones together and functions as a dynamic stabilizer during the midstance phase and toe-off.137 Activity of the tibialis posterior muscle results in an interlocking of the midfoot bones allowing the foot to function as a rigid lever during midstance and toe-off. When it relaxes, the foot becomes flexible and adaptable during heel-contact.137,146,232 
Figure 62-1
Ligamentous structure of the midfoot.
 
A: The dorsal view shows extensive overlap of the interosseous ligaments. B: The plantar ligaments are thicker than their dorsal counterparts and are dynamically reinforced by the tibialis anterior, tibialis posterior, and peroneus longus tendons. Note the extensive attachments of the tibialis posterior throughout the midfoot bones.
A: The dorsal view shows extensive overlap of the interosseous ligaments. B: The plantar ligaments are thicker than their dorsal counterparts and are dynamically reinforced by the tibialis anterior, tibialis posterior, and peroneus longus tendons. Note the extensive attachments of the tibialis posterior throughout the midfoot bones.
View Original | Slide (.ppt)
Figure 62-1
Ligamentous structure of the midfoot.
A: The dorsal view shows extensive overlap of the interosseous ligaments. B: The plantar ligaments are thicker than their dorsal counterparts and are dynamically reinforced by the tibialis anterior, tibialis posterior, and peroneus longus tendons. Note the extensive attachments of the tibialis posterior throughout the midfoot bones.
A: The dorsal view shows extensive overlap of the interosseous ligaments. B: The plantar ligaments are thicker than their dorsal counterparts and are dynamically reinforced by the tibialis anterior, tibialis posterior, and peroneus longus tendons. Note the extensive attachments of the tibialis posterior throughout the midfoot bones.
View Original | Slide (.ppt)
X
At the Lisfranc joint line the tarso-metatarsal (TMT) articulations are divided into three synovial joints and three columns59,225 (Fig. 62-2). The second and third TMT joints are the most stable ones with a maximal sagittal motion up to 0.6 mm for the second TMT joint and up to 1.6 mm for the third TMT joint, respectively. The high stability of the second TMT joint is based on bony stability as it is recessed as a keystone between the medial and lateral cuneiforms. In addition, further stability is provided by a network of strong ligaments including the plantar portion of the Lisfranc ligament running from the medial cuneiform to the base of the second metatarsal.20,132,179,301 The first TMT joint is more mobile than the second and third with a vertical range of motion of up to 3.5 mm.130,257 This is related to the more ellipsoid shape of the articulation between the medial cuneiform and the first metatarsal, compared to the immobile flat second and third TMT joints. In addition, there is no intermetatarsal ligament between the first and second metatarsal bones. These two anatomic variations are residual features from the time the human foot evolved toward bipedal gait, when the abducted, flexile first metatarsal became parallel to the second metatarsal.130,307 The fourth and fifth TMT joints have the greatest mobility with 9.6 and 10.2 mm, respectively, and function as a shock absorber during gait as they are the first metatarsal bones with ground contact after heel strike.130,332 The intrinsic mobility of the midfoot joints is very important to consider in the reconstruction of fracture–dislocations in this region. There are essential, nonessential, and unnecessary joints (Fig. 62-2). Essential joints have to be restored under all circumstances because they are important for a normal gait. The nonessential joints can be temporarily transfixed and the unnecessary joint can be fused during reconstruction.130 
Figure 62-2
Columns and essential joints of the foot: Pink.
 
The medial column of the foot. Green: the lateral column of the foot. Blue and Green lines: essential or nonessential, but useful, joints. Grey lines: unnecessary joints.
The medial column of the foot. Green: the lateral column of the foot. Blue and Green lines: essential or nonessential, but useful, joints. Grey lines: unnecessary joints.
View Original | Slide (.ppt)
Figure 62-2
Columns and essential joints of the foot: Pink.
The medial column of the foot. Green: the lateral column of the foot. Blue and Green lines: essential or nonessential, but useful, joints. Grey lines: unnecessary joints.
The medial column of the foot. Green: the lateral column of the foot. Blue and Green lines: essential or nonessential, but useful, joints. Grey lines: unnecessary joints.
View Original | Slide (.ppt)
X

Tarsal Navicular Fractures

With an incidence of 0.45% of all fractures, midfoot fractures are uncommon76 and thus the subgroup of navicular fractures is even more rare.217 The navicular is the supporting structure of the medial column of the foot. It forms one of the foot’s essential joints,132 and it bears the majority of the load applied to the foot within the tarsal complex during weight bearing.292,299 Associated ipsilateral foot injuries are a common finding and the occurrence of a tarsal navicular fracture should make the examiner alert to detect associated injuries. Based on our recent clinical observations we can anticipate seeing more severe injury patterns of the tarsal complex in the future. This is partly related to improvements in car safety resulting in increasing patient survival with severely traumatized feet.271,287 

Pathoanatomy and Applied Anatomy

The proximal concave articulation with the talar head is one of the seven essential joints of the foot.132 An average of approximately 37 degrees of range of motion makes this joint responsible for a substantial amount of midfoot motion.20 In contrast, the distal convex articulations with the three cuneiforms through separate facets are unnecessary joints,132 as well as is the inconsistent articulation with the cuboid. The tarsal navicular is recognized as the keystone within the medial column of the foot, bearing the majority of the load applied to the foot.292,299 An extensive network of plantar and dorsal ligaments attaches to the navicular and rigidly stabilizes the midfoot.132 
In 1%186 of individuals one can find an incomplete coalition as an articulation between the lateral pole of the navicular and the anterior process of the calcaneus. Frequently this coalition is asymptomatic and only discovered on radiographs obtained following an ankle sprain. When persistently symptomatic, resection of the osseous bridge can lead to a resolution of symptoms.298 The only tendon that inserts into the navicular is the anterior portion of tibialis posterior tendon medially. The navicular blood supply is provided through small branches from the dorsalis pedis and tibialis posterior arteries entering from the medial pole and the dorsal and plantar surfaces with a relatively avascular central third.348 Hence, predisposing this bone to healing disturbances. 

Fracture Mechanisms

Two distinct navicular fracture types can be differentiated, acute fractures due to direct or indirect trauma and stress fractures. The latter most often result from repetitive overload as seen in long distance runners. A variety of acute fracture patterns have been described. Depending on the injury mechanism, direct or indirect force is transmitted to the navicular bone. Direct force transmission causes avulsion fractures or crush fractures in the dorsal-plantar plane. Indirect fractures most often result from high-energy impact as seen in motor vehicle accidents or falls from a height.105 The transmitted force is directed via an axial load to the foot combined with plantar flexion and either adduction or abduction through the forefoot.105,287,340 The surrounding soft tissues and adjacent bones are likely to be traumatized and have to be included in the assessment plan of the primary fracture care.105 
The mechanism that forms the basis for the development of a tarsal navicular stress fracture is not well understood. There are several theories and risk factors for the development of a stress fracture. Chronic overloading of the talo-navicular joint due to a long second ray or a pes cavus deformity with restricted motion in the adjacent talo-navicular joint is frequently seen in physically active patients with stress fractures.26,27,304,305 

Signs, Symptoms and Imaging

The clinical appearance of a navicular fracture can range from a severely injured foot to an almost normal foot with only moderate pain. In the severely injured foot, the soft tissues have to be evaluated carefully to exclude a compartment syndrome and or ischemia of the forefoot. As a primary assessment, AP, lateral, and oblique radiographs help to understand the fracture pattern and to assess the adjacent structures. A high-resolution CT scan of the entire foot is the key diagnostic tool in evaluating and treating many navicular fractures. Haapamaki et al.128 showed that the sensitivity of primary radiography was 33% compared with CT scanning in the detection of tarsal navicular fractures. Furthermore, 3D-CT reconstructions can be helpful in understanding complex peri-navicular dislocations prior to surgical reconstruction.105 If there is any suspiciousness of a navicular stress fracture the CT scan should be of high resolution with 1 mm slices and should be orientated perpendicular to the navicular. 

Classification

The most common injuries of the tarsal navicular are avulsion, or flake, fractures.102 Acute navicular fractures are classified into three types: Avulsion fractures, fractures of the navicular tuberosity, and body fractures102 (Fig. 62-3). The latter occur predominantly from high-energy trauma and are further subdivided into three types.293 The Type I body fracture is a horizontal transverse fracture through the navicular with disruption of the dorsal ligaments. Type II body fractures usually result from abduction injury and are characterized by a vertical fracture with comminution of the lateral portion of the navicular, combined with a disruption of the talo-navicular ligament. Type III body fractures are the most comminuted fractures and are usually caused by severe axial loading with abduction and plantar flexion. The calcaneocuboid (CC) joint and the naviculo-cuneiform ligaments are frequently involved.102,131 Due to central body comminution of the navicular a loss of height of the medial arch of the foot with shortening of the medial column is frequently present. A more detailed classification system of navicular fractures is the AO/OTA classification which is more commonly used for systematic research.113 Location, direction, articular involvement, and fracture severity determine 16 subgroups of navicular fractures. This classification system was revised in 2007206,235 condensing fracture pattern into main groups of noncomminuted (AO/OTA 83-A) and comminuted (AO/OTA 83-B) types (Fig. 62-4). Also, complete tarsal navicular dislocation has been reported.86,90,282,340 Dislocations are classified based upon the joint involved as midfoot dislocation injuries of the foot, alphanumerically as 80-C.204 Subgroups include talo-navicular (80-C1), naviculo-cuneiform (80-C3), and multiple midfoot dislocations (80-C9). The latter includes isolated or complete navicular dislocation. Further subclassification by direction has not been given specific codes.204 Furthermore, crush injuries of the midfoot region including multiple foot fractures are classified as 89-B. 
Figure 62-3
The present popular classification of navicular fractures is composed of three basic types with a subclassification for body fractures suggested by Sangeorzan.293
 
A: Avulsion-type fractures can involve either the talo-navicular or naviculocuneiform ligaments. B: Tuberosity fractures are usually traction-type injuries with disruption of the tibialis posterior insertion without joint surface disruption. C: A type I body fracture splits the navicular into dorsal and plantar segments. D: A type II body fracture cleaves it into medial and lateral segments. The location of the split usually follows one of the two intercuneiform joint lines. Stress fractures are usually included in this group. E: A type III body fracture is distinguished by comminution and significant displacement of the fragments.
A: Avulsion-type fractures can involve either the talo-navicular or naviculocuneiform ligaments. B: Tuberosity fractures are usually traction-type injuries with disruption of the tibialis posterior insertion without joint surface disruption. C: A type I body fracture splits the navicular into dorsal and plantar segments. D: A type II body fracture cleaves it into medial and lateral segments. The location of the split usually follows one of the two intercuneiform joint lines. Stress fractures are usually included in this group. E: A type III body fracture is distinguished by comminution and significant displacement of the fragments.
View Original | Slide (.ppt)
Figure 62-3
The present popular classification of navicular fractures is composed of three basic types with a subclassification for body fractures suggested by Sangeorzan.293
A: Avulsion-type fractures can involve either the talo-navicular or naviculocuneiform ligaments. B: Tuberosity fractures are usually traction-type injuries with disruption of the tibialis posterior insertion without joint surface disruption. C: A type I body fracture splits the navicular into dorsal and plantar segments. D: A type II body fracture cleaves it into medial and lateral segments. The location of the split usually follows one of the two intercuneiform joint lines. Stress fractures are usually included in this group. E: A type III body fracture is distinguished by comminution and significant displacement of the fragments.
A: Avulsion-type fractures can involve either the talo-navicular or naviculocuneiform ligaments. B: Tuberosity fractures are usually traction-type injuries with disruption of the tibialis posterior insertion without joint surface disruption. C: A type I body fracture splits the navicular into dorsal and plantar segments. D: A type II body fracture cleaves it into medial and lateral segments. The location of the split usually follows one of the two intercuneiform joint lines. Stress fractures are usually included in this group. E: A type III body fracture is distinguished by comminution and significant displacement of the fragments.
View Original | Slide (.ppt)
X
Figure 62-4
The OTA classification for navicular fractures.
 
The initial differentiation is by articular involvement, Type A is extra-articular, type B has mainly uniarticular involvement and type C signifies multiarticular, multifragmented involvement. Further subdivision is by fracture pattern.
The initial differentiation is by articular involvement, Type A is extra-articular, type B has mainly uniarticular involvement and type C signifies multiarticular, multifragmented involvement. Further subdivision is by fracture pattern.
View Original | Slide (.ppt)
Figure 62-4
The OTA classification for navicular fractures.
The initial differentiation is by articular involvement, Type A is extra-articular, type B has mainly uniarticular involvement and type C signifies multiarticular, multifragmented involvement. Further subdivision is by fracture pattern.
The initial differentiation is by articular involvement, Type A is extra-articular, type B has mainly uniarticular involvement and type C signifies multiarticular, multifragmented involvement. Further subdivision is by fracture pattern.
View Original | Slide (.ppt)
X
Stress fractures of the navicular bone were first described in 1970 by Towne et al.336 and are most commonly seen in athletes comprising 14% of all stress fractures.26,48 They are classified as partial or complete and usually start near the mid dorsum of the navicular bone and progress in a plantar direction (Fig. 62-5). 
Figure 62-5
 
A: A 56-year-old female with a complete tarsal navicular stress fracture (yellow arrow) and bone bruises of the intermediate cuneiform and talar head (white arrows). One year later following closed treatment, lateral (B) and AP (C) radiographs demonstrate progressive talo-navicular joint degeneration.
A: A 56-year-old female with a complete tarsal navicular stress fracture (yellow arrow) and bone bruises of the intermediate cuneiform and talar head (white arrows). One year later following closed treatment, lateral (B) and AP (C) radiographs demonstrate progressive talo-navicular joint degeneration.
View Original | Slide (.ppt)
Figure 62-5
A: A 56-year-old female with a complete tarsal navicular stress fracture (yellow arrow) and bone bruises of the intermediate cuneiform and talar head (white arrows). One year later following closed treatment, lateral (B) and AP (C) radiographs demonstrate progressive talo-navicular joint degeneration.
A: A 56-year-old female with a complete tarsal navicular stress fracture (yellow arrow) and bone bruises of the intermediate cuneiform and talar head (white arrows). One year later following closed treatment, lateral (B) and AP (C) radiographs demonstrate progressive talo-navicular joint degeneration.
View Original | Slide (.ppt)
X
None of the present classification systems have been shown to fulfill the idealized vision of Müller to serve as a basis for treatment and evaluation of the results.236 Sangeorzan et al.293 showed that operative treatment can be based upon the type and direction of fracture displacement with a relationship between injury severity and functional outcome; however, these observations have not been substantiated statistically. 
Coulibaly et al.74 showed that most avulsion fractures result in a good functional outcome with nonoperative treatment; however, suspicion should always be present in a patient with an apparently trivial avulsion fracture, and weight-bearing radiographs should be obtained to rule out unstable injuries of the midtarsal joint complex. All too often, these complex injuries are misdiagnosed initially as simple sprains.102 

Tarsal Navicular Treatment Options

Nonoperative Treatment (Table 62-1).
 
Table 62-1
Tarsal Navicular Fractures
View Large
Table 62-1
Tarsal Navicular Fractures
Indications for Nonoperative Treatment
Nondisplaced fracture (<2 mm)
Intact medial column of the foot (Length/stability)
No major associated midfoot injuries
Stress fractures
Surgical contraindications
X
To qualify for nonoperative treatment, several clinical and radiologic criteria have to be met. First, the fracture has to be nondisplaced and without comminution nor joint involvement. Second, no other injuries of the surrounding bones are present which would indicate an associated instability and ligamentous injury. Third, the soft tissues have to be adequate to allow safe cast immobilization. Nonoperative treatment should be performed if articular displacement is less than 2 mm, if there is no evident subluxation, and there is integrity of the medial column of the foot.132,222,277 The treatment of choice is immobilization in a short-leg cast with no or toe touch weight bearing for 6 to 8 weeks. The most common injury of the tarsal navicular is an avulsion flake fractures.102 Frequently these are found in association with tears of the capsulo-ligamentous structures. Most often these can be treated nonoperatively.102,193,217,268 Larger fragments involving articular surfaces should be treated operatively.268 Following the initiation of conservative treatment, the integrity of ligamentous stability of the longitudinal and transverse arches requires reevaluation using weight-bearing plain radiographs at 1 to 2 weeks after injury or under fluoroscopic stress examination. If there is any doubt of fracture stability, open reduction and internal fixation should be pursued to secure a stable medial column. 
Nonoperative treatment for nondisplaced fractures in the form of elastic support and non-weight-bearing or plaster cast immobilization for 4 to 6 weeks has been used for decades.102 Howie et al.150 however noted a high incidence of associated injuries of the lateral column in the presence of navicular fractures. Five out of 14 patients had poor results with significant long-term morbidity and an incidence of secondary osteoarthritis of 80%. They showed that nonoperative treatment in combined injuries of the midfoot can lead to persistent disability due to instability. 
Tarsal navicular stress fractures are primarily treated conservatively.238,304,339 Non-weight-bearing cast immobilization for 6 to 8 weeks has been shown to have clinical outcomes equal to operative treatment.52,238,304,336 For both partial and complete tarsal navicular stress fractures Torg et al.334 showed in a meta-analysis that nonoperative management, including non-weight-bearing, when compared to operative fixation leads to similar outcomes with respect to fracture healing and return to preoperative level of activity. 
Operative Treatment.
Restoration of the length of the medial column of the foot and articular reconstruction form the two main tenets of surgical treatment of navicular fractures.132,289,293,294 ORIF has become a widely accepted treatment solution and can be considered as the gold standard in displaced fractures. An open approach with visualization of the fracture components facilitates restoration of both length and articular congruity.132,247,268,293 Recently Evans et al.105 reported on a cohort of high-energy navicular body fractures including 8 Type II and 16 Type III fractures treated with mini-fragment plate fixation (2.0-, 2.4-, or 2.7-mm stainless steel straight or T-plates). Overall, ORIF is reported leading to good results (Table 62-2).175,293 
 
Table 62-2
Tarsal Navicular Fractures
View Large
Table 62-2
Tarsal Navicular Fractures
Surgical Treatment
Indications Contraindications
Open fracture Compromised soft tissue coverage
Displacement ≥2 mm General health condition of the patient
Articular incongruity >1 mm Severe arterial vascular disease
Medial column instability or shortening Neuropathy
Associated multiple midfoot injuries Noncompliance
Associated compartment syndrome
X
Open Reduction and Internal Fixation.
Surgical exposure is usually performed through a dorsal incision while protecting the dorsal pedis artery and the peroneal nerve branches. Others have described a dual incision technique as optional in navicular fracture care105 (Fig. 62-6). The exposure runs from the neck of the talus to the second metatarsal bone. The extensor hallucis longus tendon and the neurovascular bundle are retracted and protected, and the fracture lines are identified. While retaining as many soft tissue attachments as possible to the fracture fragments, the fracture edges and articular fragments should be clearly exposed. In the case of a comminuted fracture pattern, the talo-navicular joint should be opened to improve visualization and facilitate reduction. If there is only a single fracture line, then the fracture is anatomical reduced and held with a sharp-pointed forceps under direct visualization through the talo-navicular joint. Anatomic articular reduction of the proximal and distal navicular articular surfaces can be facilitated by using the articular surfaces of the talar head and the cuneiforms as templates. Temporary preliminary fixation is maintained with 1.25- or 1.6-mm Kirschner wires (K-wires). We recommend filling any osseous defects with bone graft, which can be harvested via a small lateral incision over the calaneal tuberosity or at the distal medial part of the tibia. As an alternative, an allograft can be used for augmentation. Finally, cortical fragments are closed on top of the graft, and fixation is performed with either 3.5- or 2.7-mm compression screws. Cortical screws are preferred because of the smaller screw diameter. Washers may be used as one hole plates in situations with poor bone quality, and the transfixation of adjacent cuneiforms (as nonessential joints) can be performed to increase construct stability. Plate fixation is performed using small (one-third or quarter tubular plates), mini fragment (2.0-mm mini-T-plates), or 2.7-mm plates (Fig. 62-7). 
Figure 62-6
Surgical approaches to the navicular.
 
The medial incision is between the tibialis anterior and posterior tendons. The dorsal incision is just lateral to the dorsalis pedis artery and medial to the extensor tendons.
The medial incision is between the tibialis anterior and posterior tendons. The dorsal incision is just lateral to the dorsalis pedis artery and medial to the extensor tendons.
View Original | Slide (.ppt)
Figure 62-6
Surgical approaches to the navicular.
The medial incision is between the tibialis anterior and posterior tendons. The dorsal incision is just lateral to the dorsalis pedis artery and medial to the extensor tendons.
The medial incision is between the tibialis anterior and posterior tendons. The dorsal incision is just lateral to the dorsalis pedis artery and medial to the extensor tendons.
View Original | Slide (.ppt)
X
Figure 62-7
Postoperative radiographs at 3 months of a 52-year-old woman who sustained comminuted navicular and cuboid fractures as a result of a low-speed motorcycle accident.
 
Open reduction and internal fixation was performed using a 2.7-mm mini-fragment implant combined with temporary adjunct talo-metatarsal external fixation. A: Lateral view. B: AP view.
Open reduction and internal fixation was performed using a 2.7-mm mini-fragment implant combined with temporary adjunct talo-metatarsal external fixation. A: Lateral view. B: AP view.
View Original | Slide (.ppt)
Figure 62-7
Postoperative radiographs at 3 months of a 52-year-old woman who sustained comminuted navicular and cuboid fractures as a result of a low-speed motorcycle accident.
Open reduction and internal fixation was performed using a 2.7-mm mini-fragment implant combined with temporary adjunct talo-metatarsal external fixation. A: Lateral view. B: AP view.
Open reduction and internal fixation was performed using a 2.7-mm mini-fragment implant combined with temporary adjunct talo-metatarsal external fixation. A: Lateral view. B: AP view.
View Original | Slide (.ppt)
X
 
Table 62-3
Fixation of Tarsal Navicular Fractures
View Large
Table 62-3
Fixation of Tarsal Navicular Fractures
Surgical Steps
CRIF:
  •  
    Apply axial traction (via first toe) to distract across TN and NC joints
  •  
    Reduce split portion of fracture using pointed clamps percutaneously and provisionally stabilize with 0.062 K-wires
    •  
      Restore joint congruity (do not tolerate articular step-off >1 mm)
    •  
      Indirect reduction of joint component possible using 1.6-mm K-wire
    •  
      Restore column length and temporarily stabilize column using an external fixator
  •  
    Fracture fixation using at least one and, if possible, two 2.7-mm low-profile cortical screws or Herbert screws
    •  
      Increase stability using washer (low bone quality)
    •  
      Increase stability by transfixing to cuboid and/or cuneiforms
ORIF:
  •  
    Subperiosteal exposure of apical and distal navicular
  •  
    L-shape talo-navicular and/or naviculo-cuneiform arthrotomy
  •  
    Apply medial column distractor across TN and NC joints
     
    Simple fracture pattern
    •  
      Open split portion of fracture, debride fracture zone, and joint surfaces
    •  
      Preserve lateral soft tissue attachments
    •  
      Reduce split component using pointed clamps and provisionally stabilize with K-wires
    •  
      Apply 3.5 or 2.7 mm compression screws.
     
    Comminuted Fracture Pattern
    •  
      Reduce comminuted component, augment with bone graft and provisionally stabilize with 1.25-mm K-wires
    •  
      Restore joint congruity using adjacent bone as template (do not tolerate articular step-off >1 mm)
    •  
      Apply mini-fragment L-/T-plate medio-dorsal to tarsal navicular
    •  
      Assess alignment using intraoperative simulated weight-bearing x-rays in 3 planes (AP, LAT, OBL)
    •  
      Assess stability of the medial column of the foot with intraoperative dynamic fluoroscopy
    •  
      If unstable, proceed with adjunct internal/external spanning technique
X
Techniques of fixation and supplemental support can vary depending on fracture pattern. A list of the main surgical steps is provided in Table 62-3. A medial external fixator can be applied as an adjunct to ORIF. Alternatively, an internal spanning plate can be used when ligamentous instability of the adjacent joints has been identified.75 For maintenance of overall length of the medial column of the foot a four- to eight-hole 2.0-mm semitubular or 2.7-mm plate is placed over the medial aspect of the medial column of the foot. Stabilization is achieved by inserting 2.7-mm screws into the talar head or neck when proximal articular involvement or talo-navicular instability is present. Fixation of the tarsal navicular transfixing the medial cuneiform, as well as fixation to the base of the first metatarsal for distal articular injury or distal instability of the medial column, can be performed. In the case of severe destruction or nonreconstructable joint surfaces primary arthrodesis is optional. In some cases, restoration of the anatomy of the navicular bone with comminution needs to be addressed as well as ligamentous instability. An external distractor or fixator can be helpful as an adjunct to indirectly align both the medial column and the fracture site. The distractor is placed proximally into the talus or, as an alternative, into the medial malleolus and distally into the base of the first or second metatarsal to span and align the fracture site (Fig. 62-8). If stable fixation cannot be achieved by open reduction and internal fixation of the navicular, as in crush injuries to the medial column, temporary bridge plating can facilitate restoration of first ray alignment308 (Fig. 62-9). 
Figure 62-8
Reduction and fixation technique for comminuted or displaced navicular fractures.
 
A: Typical fracture pattern with medial to lateral talo-navicular disruption. B: Placement and use of an external fixator aids in restoration of length and maintenance of position for fixation. The talo-navicular joint is restored and bone graft is placed behind it to fill any void. C: Fixation screws are placed into the cuneiforms or cuboid to secure fracture stability.
A: Typical fracture pattern with medial to lateral talo-navicular disruption. B: Placement and use of an external fixator aids in restoration of length and maintenance of position for fixation. The talo-navicular joint is restored and bone graft is placed behind it to fill any void. C: Fixation screws are placed into the cuneiforms or cuboid to secure fracture stability.
View Original | Slide (.ppt)
Figure 62-8
Reduction and fixation technique for comminuted or displaced navicular fractures.
A: Typical fracture pattern with medial to lateral talo-navicular disruption. B: Placement and use of an external fixator aids in restoration of length and maintenance of position for fixation. The talo-navicular joint is restored and bone graft is placed behind it to fill any void. C: Fixation screws are placed into the cuneiforms or cuboid to secure fracture stability.
A: Typical fracture pattern with medial to lateral talo-navicular disruption. B: Placement and use of an external fixator aids in restoration of length and maintenance of position for fixation. The talo-navicular joint is restored and bone graft is placed behind it to fill any void. C: Fixation screws are placed into the cuneiforms or cuboid to secure fracture stability.
View Original | Slide (.ppt)
X
Figure 62-9
Navicular spanning internal fixation modified according to Schildhauer et al.308
Rockwood-ch062-image009.png
View Original | Slide (.ppt)
X
Restoration of column length and prevention of collapse can be achieved. The plate serves as an internal buttress with screws positioned in the talar head, cuneiforms, and the base of the first metatarsal. Although the internal spanning device can provide stable fixation, mild distraction should be preserved and the hardware should be removed after bony consolidation and before the beginning of unprotected weight bearing (Table 62-4). 
Table 62-4
Adjunct Internal Spanning Fixation of Tarsal Navicular Fractures
Surgical Steps
  •  
    See surgical steps for CRIF/ORIF
  •  
    Apply medial column distractor across TN and NC joint
    •  
      Place first 2.5-mm Schanz pin in talar body/head
    •  
      Place second 2.5-mm Schanz pin in medial cuneiform or base of first MT parallel to joint surface
    •  
      Apply axial talo-MT traction (using two bars improves stability)
    •  
      Assess alignment in AP, LAT, and OBL projection and, if necessary, correct malalignment prior to plate fixation
  •  
    Apply 2.7-mm small fragment or one-third tubular plate bridging talo-navicular and/or naviculo-cuneiform joints to address column instability
    •  
      Alone or in combination with ORIF
    •  
      Use 2.7-mm cortical screws
    •  
      Increase stability by transfixing to cuboid and/or cuneiforms
  •  
    Remove distractor
    •  
      Reassess alignment via simulated weight-bearing x-rays
    •  
      Reassess stability via dynamic fluoroscopy
X
Adjunct External Fixation.
As an adjunct to closed reduction and internal fixation with screws or K-wires, external fixation for 6 weeks or longer is an option. Restoration and maintenance of the length of the medial column of the foot can be achieved; however, the disadvantage is that with articular involvement the impacted zones are not restored. Chandran et al.58 reported on external fixator application in 11 open midfoot injuries. In six cases a navicular fracture was present. The fixators were removed at an average of 9 weeks. Two pin tract infections occurred. At 1-year follow-up all patients had functional feet, but pain was present in six patients. Richter et al.289 also reported on the supplemental use of external fixators in 35.5% of 148 operatively treated patients with midfoot fractures. However, the value of external fixators as an adjunct to ORIF in navicular fracture care is not sufficiently supported by the present literature. 
Bone Grafting.
Bone grafting is recommended for restoration of bony integrity and to promote healing.175,281,293 The site of origin varies and usually cortico-cancellous grafts are taken from the iliac crest289,293 or the proximal tibial metaphysis.132 Local cancellous bone is an alternative but for stable bony support cortico-cancellous blocks are recommended.289,293 Four out of 21 patients received bone grafts during ORIF in the largest reported series of operative navicular fracture treatment.293 In the European literature the use of bone grafting has been emphasized.291,278,281 In a recent study bone grafting was found to facilitate reduction and articular reconstruction.71 Furthermore, a relation to improved reduction quality was evident. However, bone grafting did not improve convalescence, clinical, or functional outcome, a finding that has been reported also for calcaneal fracture care.190 
In the face of comminuted fracture patterns, we recommend the use of autologous bone grafting as it facilitates anatomical restoration and promotes fracture healing by its osteoconductive and osteoinductive effects. 
Primary Arthrodesis.
Primary arthrodesis is an option if reconstruction of articular surfaces in the face of severe comminution and destruction is not viable. In the case of navicular bone loss of more than 40%, primary talo-navicular arthrodesis has been recommended to achieve adequate stability of the first ray.267 In contrast, fusion of the naviculo-cuneiform joint has been recommended to facilitate reconstruction of a severely destroyed tarsal navicular, preserving the mobile talo-navicular joint, and leading to a better functional outcome.192,268 However, fusion remains a salvage procedure for most authors.175,268 Talo-navicular joint fusion may not be well tolerated by patients as it locks the talo-calcaneo-navicular complex resulting in foot stiffness.175 However, Fishco and Cornwall111 provided evidence that isolated talo-navicular arthrodesis can lead to satisfactory results, although, a reduction in muscle strength and ankle kinematics may occur. Richter et al.289 showed in a series of 148 midfoot fractures that primary fusion was seldom necessary (an incidence of 4.7%) in operatively treated cases. From our clinical practice primary arthrodesis in navicular fracture treatment is related to unsatisfactory results and revision surgery can be expected. 
Postoperative Care.
After operative fixation of navicular fractures immobilization is required for 5 to 6 weeks in a removable walker or cast. The removable walker provides safe tissue monitoring and comfort for the patient. Patients require training in the proper use of the walker, and if patient compliance is in doubt a well-molded short-leg plaster cast with the foot in a plantigrade position is preferable. Non-weight-bearing should be maintained for 6 weeks after operative treatment. Standardized weight-bearing radiographs and clinical assessment are performed at 4 and 8 weeks after the operation. If healing is progressing and the patient is pain free, partial weight bearing can be allowed until the 10th to 12th week. 
Standard radiographic follow-up imaging should assess column alignment, progress of healing, loss of reduction, implant failure, and development of post-traumatic osteoarthritis and deformity. To detect the development of secondary deformity, standardized weight-bearing AP and lateral radiographs are used to determine the talo-metatarsal angle, calcaneal pitch angle, navicular and cuboid ground distances, talo-navicular coverage angle (NCA), and medial and lateral column length. If bony consolidation is not clearly seen on standard radiographs at the 10th to 12th week mark, a CT scan should be obtained. If healing is delayed, secondary bone grafting should be discussed with the patient or the time of immobilization should be prolonged. 
Usually at 6 to 8 weeks a vigorous physical exercise program is started out of the walker to restore mobility of the essential joints. In patients with a temporary bridge plate or adjunct external fixation of the medial column, the spanning device should be removed at 12 weeks after the index operation at least across the talo-navicular joint. This will allow restoration of motion at the midtarsal joint complex (Chopart’s). Hardware can be left in situ when bridging nonessential or unnecessary joints. Eventually, most patients will require shoewear modifications using orthotics or an extended steel shank, and customized shoewear is adjusted in more complex foot injuries to increase mobility and improve walking. 

Outcomes and Complications

Despite satisfactory reductions and high rates of union, fractures of the navicular have severe impact on long-term clinical and functional outcome. McKeever217 noted that because of the damage to the articular cartilage at the time of injury, severe traumatic arthritis of the talo-navicular joint often develops resulting in loss of rotational flexibility and pain. Sangeorzan et al.293 concluded that fractures of the body most often result in severe long-term disability. Patients with less severe fracture patterns and fewer associated injuries should perform better in the long run.289 
During the acute phase of healing the most frequent complications in the treatment of navicular fractures are soft tissue problems. These need special attention and often have to be treated aggressively to avoid chronic infections. Local soft tissue flaps or skin grafts are not the best solutions because of the overall thin soft tissue coverage of the foot. With thin free vascularized flaps, such as parascapular or lateral thigh flaps, good coverage and satisfying cosmetic results can be achieved even in lager defects. 
Pain is a major contributor to long-term disability in foot injuries.58,84,86,193,335 It is known to be subjective and difficult to measure. Pain in the traumatized foot is most often a result of post-traumatic arthritis,88,153,217,222 implants,13,289,308 and neuromas.3,88,246,281 Sangeorzan et al.293 reported fair or poor results, including persistence of pain in one-third of their patients and no residual disability in only 19%. Nonoperative treatment102,142 and primary fusion161 can lead to full recovery, but also after operative navicular fracture treatment full recovery has been reported.173 Higher amount of discomfort are seen in crush and medial column injuries.349 
The most common sequela complicating navicular fracture is the development of post-traumatic osteoarthritis.132 The early onset of arthritis has been reported following navicular fractures,13,102,218 and degenerative changes after fracture–dislocation of the tarsal navicular, especially at the talo-navicular joint, have been described after both nonoperative and operative treatment.150,153,218 We have observed a high rate of pain related to secondary arthritis, particularly following more severe fracture patterns. 
Both nonunion and osteonecrosis have been reported following navicular fracture.3,88,222,277,278 The poorly vascularized central zone of the navicular body348 has been identified as a risk factor for the development of healing disturbances after trauma; however, current evidence does not support a higher susceptibility for healing disturbances of the navicular after acute trauma. Nevertheless, nonunion is a rare complication and it is more common in more severe fracture types.293 In one of the largest series of midfoot injuries no healing disturbance (nonunion or osteonecrosis) was described.289 
Nonunion of the tarsal navicular with a correct length of the medial column requires bone grafting and proper fixation. If the first ray has collapsed, secondary reconstruction is required to restore the medial column anatomy. Several operative techniques have been described to reestablish foot alignment.132 Medial column lengthening with iliac crest graft interposition, and opening wedge osteotomies for lengthening and flexion-correction of the first ray are options. The development of a pes planus deformity after midtarsal injuries has also been described.58,150,281 Coulibaly et al.73 reported an incidence of 21% of pes planus and 26% of pes cavus deformities after navicular fracture care. Revision surgery will be performed most commonly to treat persistent pain and secondary osteoarthritis. However, even after arthrodesis the majority of patients will experience persistent pain, will require orthopedic shoe support, and will not return to a normal level of activity. 

Author’s Preferred Treatment

 
 

Stable, nondisplaced navicular fractures are treated primarily conservatively with immobilization in a walking cast for 6 to 8 weeks. If there is any doubt regarding instability the patient is examined under fluoroscopy or standing-weight–bearing radiographs are performed. The dynamic examination under fluoroscopy is in our hands a very helpful and precise diagnostic tool to guide treatment and give accurate information about the stability of each column of the traumatized foot. When the indication for operative treatment has been confirmed, the final decision for operative intervention is left to the discretion of the patient. In a detailed dialogue, treatment options are outlined and common risks and complications are described.

 

At surgery, the patient is positioned in the supine position on a translucent table. The leg can be placed on a triangular cushion to create a plantigrade foot position when using the C-arm (Fig. 62-10).

 
Figure 62-10
 
The patient is positioned with a 15-degree bolster under the ipsilateral hip and a triangular cushion under the knee to bring it to 90 degrees of flexion and achieve a neutral position of the foot.
The patient is positioned with a 15-degree bolster under the ipsilateral hip and a triangular cushion under the knee to bring it to 90 degrees of flexion and achieve a neutral position of the foot.
View Original | Slide (.ppt)
Figure 62-10
The patient is positioned with a 15-degree bolster under the ipsilateral hip and a triangular cushion under the knee to bring it to 90 degrees of flexion and achieve a neutral position of the foot.
The patient is positioned with a 15-degree bolster under the ipsilateral hip and a triangular cushion under the knee to bring it to 90 degrees of flexion and achieve a neutral position of the foot.
View Original | Slide (.ppt)
X
 

The foot is exsanguinated and a tourniquet is applied. The first step is always a comprehensive clinical and radiographic reevaluation of the stability of the medial and lateral columns and the adjacent joints. Avulsion fractures of the dorsal navicular should be fixed if an articular step-off is identified, and articular incongruity of more than 2 mm is present. An avulsion fracture of the medial tuberosity is also fixed if displaced, as ongoing pull of the tibialis posterior tendon can provoke further displacement. In this case reduction with a pointed reduction clamp is followed by 2.7-mm screw fixation supported with a washer. Most often this can be achieved using a percutaneous technique.

 

When opting for an open approach to fix a navicular fracture, the skin incision is centered straight over the navicular and lateral to the tibialis anterior tendon. The dissection is performed with the tendon of the extensor hallucis longus identified and the neurovascular bundle retracted. A distractor or medial external spanning fixator can be mounted from the talar neck to the cuneiforms to increase visibility and indirectly reduce fragments by ligamentotaxis. The optimal Schanz pin placement is determined during surgery and usually includes placement of a proximal pin medially into the talar neck perpendicular to the talar axis. The second pin is bicortically anchored perpendicular to the long axis in the base of the first metatarsal. Pin placement is not recommended in the medial malleolar bone as the bony area for fixation is small and the spanning direction is not optimal. If the lateral column shows signs of instability as well, a lateral column fixator is introduced spanning from the calcaneal tuberosity to the base of the fifth metatarsal.

 

When exposing the fracture site we usually try to maintain the soft tissue attachments to large fracture fragments if possible to preserve blood supply. After debridement, the large fragments are addressed first. A pointed reduction clamp can be used to directly reduce the major fragment which is fixed using 2.7-mm low-profile screws. Typically, two screws are required to control rotation and increase fixation stability. In some cases reduction is tricky and impossible by direct means. In this case, one or two 1.25-mm K-wires can be placed into the body of the fragment to serve as joysticks. With the fragment directed into its original position, temporary K-wire fixation is performed, followed by screw fixation. To avoid prominence of the screw heads and to prevent cortical avulsion when introducing the head of the screw in an inclined fashion we prefer to create a trough by countersinking the head of the screw.

 

A two-fragment fracture may be treated percutaneously with screw fixation. However, the talo-navicular joint requires anatomic reduction to decrease the risk of secondary osteoarthritis. If there remains any doubt about achieving an optimal reduction, opt for open reduction and internal fixation. In the case of comminuted fractures, we usually start by identifying the largest fragment. After anatomic reduction and provisional K-wire fixation of this piece, smaller fragments are reduced onto it. The adjacent articular surfaces of the talar head and cuneiforms can serve as templates for joint reconstruction. The comminuted navicular fracture usually requires more stable support, hence, autologous bone grafting into the zone of impaction is recommended to restore its body, increase stability, and support healing. Following reduction and bone grafting, a 2.0- or 2.4-mm longitudinal plate is molded along the dorsal surface of the navicular body and secured with converging or crossing screws. Beware of the lateral corner of the tarsal navicular, as this is often insufficiently addressed. The lateral corner is difficult to visualize as it turns downward to articulate with the cuboid. To prevent shortening, and thus increase the risk of abduction deformity resulting in longitudinal arch collapse, this corner requires proper restoration. If small fragments cannot be sufficiently reduced bridge plate osteosynthesis is an option. A 2.7-mm reconstruction plate, a semi-tubular plate, or a 3.5-mm small-fragment plate is placed anteromedially or straight dorsally to bridge from the talar head to a cuneiform or metatarsal (Fig. 62-11).

 
A: Anterior–posterior view. B: Lateral view.
View Original | Slide (.ppt)
Figure 62-11
Adjunct bridge plating of the medial column of the foot in a patient with a displaced navicular fracture.
A: Anterior–posterior view. B: Lateral view.
A: Anterior–posterior view. B: Lateral view.
View Original | Slide (.ppt)
X
 

As an alternative, one can also perform bridging screw osteosynthesis into the cuneiforms. Although the primary goal is stability within the tarsal complex and the columns of the foot, respectively, temporary transfixation of essential joints should be avoided so as not to compromise their mobility. It is paramount to avoid screw placement from the navicular into the cuboid which would interfere with the mobile interplay between the medial and lateral columns of the foot. Elimination of motion at the naviculo-cuneiform joints increases stability within the medial tarsal complex and can be performed at any time without interfering with the functional results. If confronted with severely destroyed articular surfaces or nonreconstructable comminution, primary fusion remains as a salvage procedure. We usually stabilize the medial column with a 2.7-mm reconstruction plate to obtain optimal stability. However, the goal of fusion should be restoration of axial alignment and the length of the medial column, as well as stability while avoiding medial-to-lateral column fixation.

 

When treating navicular fractures always be aware of associated foot injuries and check for fractures of the cuboid, the anterior process of the calcaneus, and the talar head/neck, as well as subtalar injuries. In complex ligamentous foot injuries we typically start with reconstruction and stable fixation of the medial column. However, in severe crush injuries of the medial column, when there are major large fragments in the lateral column, it might be easier to start with reconstruction of the lateral column to restore overall foot length and to have a template for medial column alignment. After osteosynthesis has been accomplished, transfixing K-wires can be removed. However, if gross instability remains involving the essential joints, temporary K-wire transfixation can be left in situ for 6 weeks until capsulo-ligamentous healing has occurred. Before removing the medial column distraction device, we usually reevaluate stability of the medial and lateral columns and the adjacent joints under fluoroscopy. The connecting bar(s) can be removed with the Schanz pins being left in place and ab-/adduction and in-/eversion stress maneuvers can be performed. If the medial column remains unstable the fixator is left in situ for an additional 6 weeks (Fig. 62-12).

 
Figure 62-12
An algorithm for navicular fracture care.
 
NF, navicular fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
NF, navicular fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
View Original | Slide (.ppt)
Figure 62-12
An algorithm for navicular fracture care.
NF, navicular fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
NF, navicular fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
View Original | Slide (.ppt)
X

Cuboid Fractures

In the management of cuboid fractures documented cases and series are sparse and therapy strategies remain empirical and controversial. Fractures of the cuboid bone are known to be uncommon and usually are not isolated. To date no specific epidemiologic evaluation provides data on the occurrence within the modern industrial population. Bearing in mind that midfoot fractures, comprising the cuboid, have a reported incidence of 0.45%,76 injuries to the cuboid and its ligamentous attachment should be seen in less than 5.0 injuries per 100,000 population. Our own observations have shown a unimodal distribution affecting predominantly younger men.70 Contrary to the proposal that, because of its protected anatomical position, buttressed between the calcaneus and the bases of the fourth and fifth metatarsals, the cuboid fracture would rarely need reduction217 and most often treatment would be nonoperative,142 we are now aware, that with displaced fractures, length restoration and articular reconstruction are desired. Taking this into account, nonoperative treatment does not seem to be advantageous for displaced fractures. Reported results of functional outcomes of the fracture are rare. 

Epidemiology and Applied Anatomy Relating to Cuboid Fractures

The anatomical boundaries make the cuboid bone a keystone within the lateral column of the foot. It articulates with the calcaneus, navicular, lateral cuneiform, and lateral two metatarsals, and is an important stabilizer of this column.142,358 As a static, stabilized, supporting structure within the lateral column, the cuboid is susceptible to direct lateral forefoot forces or to indirect forces through foot abduction.193 The most common injury type is an avulsion fracture associated with a sprain.142 Furthermore, cuboid avulsion fractures are frequently seen in conjunction with tears of the calcaneo-cuboidal ligament and other capsulo-ligamentous structures. Crush fractures result from direct force applied to the dorso-lateral tarsus. Displaced fractures or dislocations are usually associated with other midfoot fractures or ligament injuries94 such as tarsometatarsal (TMT) fractures,328 subtalar fracture–dislocation,83 navicular fractures,98,151 or a Chopart joint dislocation.150,153,193,289,295,318,335 
Main and Jowett193 emphasized the occurrence of concurrent injuries stating that navicular fractures should not be considered in isolation. Howie et al.150 showed a high incidence of associated CC joint injuries in the presence of navicular fractures. In 14 patients with navicular avulsion fractures half showed CC joint injuries and 71% had poor results. Cuboid fractures with associated medial column injuries have a high rate of persistent problems,317 and patients with isolated midfoot fractures have better results compared to those with combined injuries to the Lisfranc joint and/or Chopart joint.245,289 

Signs, Symptoms, and Imaging of Cuboid Fractures

Hermel and Gershon-Cohen142 coined the term “nutcracker fracture” and first described the clinical appearance after an indirect injury mechanism including the sudden onset of pain and an inability to bear weight. Swelling and local tenderness along the dorsal tarsus are common findings. Palpation along the lateral column reveals pain in the area of the CC and/or lateral TMT joints. The clinical appearance can vary from a normal appearing foot with subtle signs of injury to a severely mangled extremity. Following crush and high-energy injuries, the examiner must be mindful of the soft tissue envelope (blistering, hematoma, degloving, skin necrosis) to exclude presence of compartment syndrome or ischemia. Standard radiographic imaging should include AP, lateral, and oblique views. The normal anatomic alignment of the lateral TMT complex should be assessed by evaluation of the position of the cuboid in relation to the bases of the fourth and fifth metatarsals. In the oblique projection of the normal foot the medial border of the base of the fourth metatarsal is colinear with the medial border of the cuboid and the medial borders of the lateral cuneiform and third metatarsal are also colinear. Malalignment of 1 mm or more has been characterized as diagnostic for TMT injuries.181 As described by Coss et al.68 the lateral TMT joint complex should be assessed for stability using ab-/adduction dynamic radiographic stress testing. The position of the base of the fourth metatarsal on the oblique projection is the key factor in the assessment of the TMT complex. Even though major injuries to the cuboid can be well visualized on standardized plain radiographs (especially the oblique view) in many cases differentiation of the medial border, the medio-plantar border, and in some instances the CC joint can be difficult. Therefore, when a cuboid injury is suspected, CT imaging with multidimensional reconstructions is our modality of choice. The CT scan facilitated the determination of fracture pattern and dimension, fracture fragment and joint displacement, articular involvement, and associated injuries of the foot—especially of the medial column and the TMT joint complex.178 
Finally, the “cuboid syndrome,” painful subluxation of the cuboid, is a known problem in professional athletes.106,230 The incidence varies depending on the population studied and is highest at approximately 18% in ballet dancers.2,212,273 Major findings are pain radiating along the lateral tarsal column to the anterior ankle, the fourth ray, or the plantar aspect of the midfoot.212 Forefoot push off is characterized by complaints of weakness. Chopart joint mobility is reduced. The injury mechanism has been related to forced midfoot pronation in relation to the hindfoot during axial loading. Others230 have proposed repetitive flexion/inversion stresses of the ankle as a factor leading to plantar or dorsal subluxation of the cuboid. Marshall211 described a closed reduction maneuver, the “cuboid squeeze,” as an effective measure as it provides better control of the direction and intensity of the reduction force. Conservative treatment can usually result in a full return to previous level of profession.2 

Classification of Cuboid Fractures

Sangeorzan and Swiontkowski295 described four different fracture patterns in isolated cuboid fractures: a crush injury, a proximal articular, a distal articular, and a combined fracture pattern. Weber and Lochner349 divided cuboid fractures into two types. One type included fractures with extension into the distal cuboid-metatarsal joint with involvement of the dorso-lateral or plantar-lateral wall, and the second group were burst fractures with column shortening. No extra-articular fractures have been described. 
Pediatric cuboid fractures are rare142,148,356 and to date an age-dependent characterization of cuboid fracture pattern has not been established. 
In the AO/OTA classification,113 cuboid fractures (body area No. 76) were originally subdivided into 13 groups according to fracture location, direction, articular involvement, and fracture severity. With the 2006 and 2007 revised classification of AO235 and OTA206 the two systems have been unified and the subcategories had been condensed to noncomminuted (84-A) and comminuted (84-B) fracture types, a fact that may require further investigation in the future as it seems oversimplified from our perspective (Fig. 62-13). Cuboid dislocations are classified as: CC (80-C2), cuboido-cuneiform (80-C4), tarsal-metatarsal (80-C5), and complete cuboid dislocations (80-C9) (Fig. 62-14).204 Cuboid dislocation occurs rarely with only a minority of case reports in the literature.53,54,91,94,176 
Figure 62-13
OTA classification of cuboid fractures.
 
Higher letters and numbers denote more significant injury.
Higher letters and numbers denote more significant injury.
View Original | Slide (.ppt)
Figure 62-13
OTA classification of cuboid fractures.
Higher letters and numbers denote more significant injury.
Higher letters and numbers denote more significant injury.
View Original | Slide (.ppt)
X
Rockwood-ch062-image014.png
View Original | Slide (.ppt)
Figure 62-14
OTA classification of cuboid dislocations.
Rockwood-ch062-image014.png
View Original | Slide (.ppt)
X

Cuboid Fracture Treatment Options

Nonoperative Treatment.
Due to the paucity of evidence-based information, the orthopedic surgeon must rely on recommendations drawn from case reports,94,98,120,151,176,291,318,328 case series38,142,294,310,311,335,349 or on standard text books132 leaving treatment strategies empirical and controversial. Nonoperative treatment should be pursued if articular displacement is less than 2 mm, there is no evidence of subluxation, and the lateral column of the foot is preserved. The treatment of choice is immobilization in a short-leg cast with non-weight-bearing for 6 to 8 weeks.11,335 Stark et al.318 concluded from a case report on occult fracture-subluxation of the midtarsal joint that conservative treatment could be sufficient in patients which are seen early after injury. 
Avulsion flake fractures are the most common injury of the cuboid.142 Frequently these are found in association with tears of the capsulo-ligamentous structures. Main and Jowett193 reported on 11 avulsion fractures of the medial and seven of the lateral column. Inversion strains resulted in flake fractures of the dorsal margins of the talus or navicular and lateral margins of the calcaneus or cuboid. They concluded that lateral strain injuries would be the result of valgus directed forces to the forefoot resulting in dorsal avulsion of the talus or navicular concomitant with an impaction fracture of the cuboid or calcaneus. All of these injuries were treated with plaster cast immobilization or strapping and resulted in excellent (8/11) or good (3/11) results for medial strain injuries and excellent (5/7) or fair (2/7) results for lateral strain injuries. No secondary surgical intervention was necessary.193 Others have emphasized that especially in lateral sprains the potential for more serious injuries should be taken into account.84 In one series of 13 CC ligament tears two had an avulsion cuboid fracture.11 These injuries were treated nonoperatively with immobilization for 6 weeks. One patient was eventually operated upon because of persistent complaints and CC instability. 
Taking these good results into account, nonoperative treatment should be considered for most avulsion fractures.193 But suspicion should always be present in patients with trivial avulsion fractures, and weight-bearing radiographs should be obtained to rule out unstable injuries of the midtarsal joint complex. All too often, these complex injuries are still misdiagnosed as simple sprains (Table 62-5). 
 
Table 62-5
Cuboid Fractures
View Large
Table 62-5
Cuboid Fractures
Indications for Nonoperative Treatment
Nondisplaced fracture (<2 mm)
Intact lateral column of the foot (Length/stability)
No major associated midfoot injuries
Avulsion fractures
Surgical contraindications
X
Operative Treatment.
In contrast to earlier recommendations, an operative approach is now favored for displaced cuboid fractures. With our modern understanding of functional anatomy, reconstructive acute fracture care aims to restore the length of the lateral column of the foot, as well as the articular surface.96,132,151,289,295,349 A variety of operative treatment options such as K-wire placement,98,176 screw fixation,295 and plating95,132,295,349 have been described. Overall, ORIF has been reported to lead to good results.94,295,349 Nevertheless, patients can have persistent pain even following an open approach. Indications and contraindications for surgical treatment are presented in (Table 62-6).349 
 
Table 62-6
Cuboid Fractures
View Large
Table 62-6
Cuboid Fractures
Surgical Treatment
Indications Contraindications
Open fracture Compromised soft tissue coverage
Displacement ≥2 mm General health condition of the patient
Articular incongruity >1 mm Severe arterial vascular disease
Lateral column instability or shortening Neuropathy
Associated multiple midfoot injuries Noncompliance
Associated compartment syndrome
X
Reduction and Internal Fixation.
The steps of reduction and fixation of cuboid fractures are outlined in Table 62-7
 
Table 62-7
ORIF of Tarsal Cuboid Fractures
View Large
Table 62-7
ORIF of Tarsal Cuboid Fractures
Surgical Steps
CRIF:
  •  
    Apply axial traction (via fifth toe) to distract across CC and CMT joint
  •  
    Reduce split portion of fracture using pointed clamps percutaneously and provisionally stabilize with 1.25-mm K-wires
    •  
      Restore joint congruity (do not tolerate articular step-off >1 mm)
    •  
      Indirect reduction of joint component possible using 1.6-mm K-wire
    •  
      Restore column length and temporarily stabilize column using an external fixator
  •  
    Fracture fixation using at least one or, if possible, two 2.7-mm low-profile cortical screws
    •  
      Increase stability using washer (low bone quality)
    •  
      Increase stability transfixing to calcaneal and/or metatarsals
    •  
      WARNING: Transfixation to navicular or cuneiform should be avoided to prevent interference of mobility between medial and lateral columns
ORIF:
  •  
    Subperiosteal exposure of apical and distal cuboid bone
  •  
    L-shape calcaneo-cuboidal and/or cuboido-metatarsal arthrotomy
  •  
    Apply lateral column distractor across CC and CMT joint
  •  
    Simple fracture pattern
  •  
    Open split portion of fracture, debride fracture zone and joint surfaces
    •  
      Preserve medial soft tissue attachments (vascularity)
    •  
      Reduce split component using pointed clamps and provisionally stabilize with K-wires
  •  
    Restore column length using a distractor or external fixator
  •  
    Comminuted fracture pattern
  •  
    Reduce comminuted component, augment with bone graft and provisionally stabilize with 1.25-mm K-wires
    •  
      Restore osseous anatomy
    •  
      Restore joint congruity using adjacent bone as template (do not tolerate articular step-off >1 mm)
  •  
    Apply mini-fragment X-/H-plate dorsalaterally to cuboid
  •  
    Assess alignment using intraoperative simulated weight-bearing x-rays in 3 planes (AP, LAT, OBL)
  •  
    Assess stability of the lateral column of the foot with intraoperative dynamic fluoroscopy
  •  
    If unstable, proceed with adjunct internal/external spanning technique
X
Adjunct Internal Spanning Plating.
Temporary bridge plating of the medial column of the foot is a treatment option in some midfoot and crush injuries308 and is similarly optional for the lateral column in cuboid fracture care (Fig. 62-15). For the cuboid, the plate serves as an internal buttress with screws positioned into the calcaneus and the base of the fourth metatarsal. The internal spanning device allows stable fixation and minimizes loss of fixation. Indications for spanning plates are comminuted fracture patterns and instability of the adjacent joints. Typically a 2.7-mm reconstruction plate (most often 10-hole plate) is used. In some circumstances application of a 2.0-mm 1/3-tubular plate is necessary bearing in mind that the strength of stability will be reduced. Distraction of the CC joint should be achieved following the conceptual strategy of temporary medial column stabilization.308 An important principle of modern reconstructive foot surgery is to retain motion at the essential joints of the foot132 as absence of adaptive mobility of the foot predisposes to accelerated degenerative arthritis.61 Even though the CC joint is not an essential joint,132 it is our opinion that the comminuted joint surfaces of the cuboid should not be compressed, and therefore mild distraction after reconstruction should be applied. Hardware removal is required after fracture consolidation and before the beginning of unprotected weight bearing (Table 62-8). 
Figure 62-15
Schematic of adjunct internal (right) and external (left) spanning fixation in cuboid fracture care.
Rockwood-ch062-image015.png
View Original | Slide (.ppt)
X
 
Table 62-8
Adjunct Internal Spanning Fixation of Cuboid Fractures
View Large
Table 62-8
Adjunct Internal Spanning Fixation of Cuboid Fractures
Surgical Steps
  •  
    See surgical steps for CRIF/ORIF
  •  
    Apply lateral column distractor across CC and CMT joint
    •  
      Place first 2.5-mm Schanz pin in the anterior process of the calcaneus
    •  
      Place second 2.5-mm Schanz pin in the base of the 4th/5th metatarsals parallel to the joint surface
    •  
      Apply axial calcaneo-MT traction (using two bars improves stability)
    •  
      Assess alignment in AP, LAT, and OBL projections, if necessary correct malalignment prior to plate fixation
  •  
    Apply 2.7-mm small fragment or 1/3 tubular plate bridging calcaneo-cuboid and/or cuboido-metatarsal joints to address column instability
    •  
      Single plate or in combination with ORIF
    •  
      Use 2.7-mm cortical screws
    •  
      Increase stability by transfixing to cuneiforms
  •  
    Remove distractor
    •  
      Reassess alignment via simulated weight-bearing x-rays
    •  
      Reassess stability via dynamic fluoroscopy
X
Adjunct External Fixation.
External fixation can be used as primary treatment tool. Lateral column length restoration and maintenance can be achieved in closed and open procedures.95,132 The fixator can be left in situ for 4 to 6 weeks to neutralize compression forces.132 If articular involvement is present use of external fixation alone has the disadvantage that the impacted zones have not been restored although adequate length has been reestablished. Richter et al.289 reported on the supplemental use of external fixators in 35.5% of 148 operatively treated patients with midfoot fractures. Weber et al.349 showed good results in a case series of 12 patients with operative cuboid fracture treatment without the application of external fixation. Restoration of the lateral column of the foot was achieved in all patients. The value of external fixators as an adjunct to ORIF in cuboid fracture care has not been sufficiently reported in the present literature. However, our clinical experience suggests that the use of external fixation as an adjunct to ORIF for stabilization of the lateral column is safe with only a minor risk of surgical complications.75 External fixators can easily be removed without anesthesia during an out-patient visit. But still the risk for pin site infection and secondary loosening of the fixator with loss of reduction remains. 
Bone Grafting.
Bone grafting is recommended to restore bony integrity and promote healing and remodeling.11,98,295 The site of origin varies and usually cortico-cancellous grafts are taken from the iliac crest98,151,295,349 or the proximal tibial metaphysis.132 Local cancellous bone is an alternative but for stable bony support cortico-cancellous blocks are recommended.319 Seven out of twelve patients received bone grafts during ORIF in the largest reported series of cuboid fracture treatment.349 Also Sangeorzan et al.295 emphasized the value of grafts. Actually there is no evidence supporting that bone graft influences reduction quality or clinical or functional outcome. However, from a technical standpoint the use of graft in the setting of comminuted fractures facilitates anatomical restoration and its sustainment and is therefore recommended. 
Primary Arthrodesis.
Primary arthrodesis is optional if reconstruction of articular surfaces in the face of severe comminution and bone destruction is not viable. Hermel and Gershon-Cohen142 outlined the value of primary lateral midtarsal fusion. Dewar and Evans84 however recommended fusion of the CC joint only in late symptomatic cases as functional loss in mobility of this joint is negligible,20 and fusion has been recommended as a salvage procedure by others.150,295,349 In contrast, cuboid-metatarsal joint fusion is in general not well tolerated by patients,268 and the creation of a pseudoarthosis or arthroplasty is favored over fusion.132 We agree that lateral column fusion should be reserved for late symptomatic cases.84,98,335 This is contrary to reports showing early functional recovery after primary fusion.142 
Postoperative Care.
Cuboid fracture treatment requires immobilization for 5 to 6 weeks in a below-knee cast or walker. The walker provides increased patient comfort but in some circumstance patients will remove it at their discretion, and thus, sufficient immobilization might be interrupted. For noncompliant patients, we prefer to apply a well-molded below-knee cast at the time of wound healing. The foot should be positioned in a neutral, plantigrade position. The patient is instructed in non-weight-bearing for 6 weeks. Therefore, clinical reevaluation and radiographic assessment will determine progression to partial weight bearing for an additional 6 weeks. A CT scan can be performed if consolidation is questionable or if pain persists at 10 to 12 weeks. At 6 to 8 weeks a vigorous exercise program is initiated to restore foot mobility. In patients with a temporary bridging plate of the lateral ray, the plate should be removed at 3 months to allow for restoration of motion at the midtarsal joint. Shoe modifications with orthotics or an extended steel shank can help to increase mobility. 
During follow-up, radiographic analysis is performed to identify fracture healing but it is also required to identify the development or presence of complications such as hardware failure (loosening, breakage), nonunion,181 osteoarthrosis,70 and secondary deformity.69,72,163 Commonly standardized weight-bearing AP and lateral radiographs are obtained for analysis at intervals of 6 weeks. However, the optimal time interval has not been determined. 

Outcomes and Complications

The development of flatfoot deformity in patients sustaining midtarsal injuries has been described sporadically.58,150,281 Lateral column shortening as a result of insufficient cuboid reconstruction, secondary collapse, or lateral column instability can lead to midfoot abduction.151 Furthermore, healing with shortening of the lateral column has been reported after cuboid fracture treatment.335 
Radiographic measures in conjunction with a thorough clinical examination are useful when analyzing if an underlying post-traumatic deformity is responsible for the persistence of pain or disability. Radiographic imaging should be obtained in the fully weight-bearing patient without use of any assistive devices. If suspicious radiographic measures are present, a comparative analysis of the contralateral side, if uninjured, is recommended to discriminate pathologic findings from the individual’s norm. If the clinical examination can be matched to conspicuous radiographic findings infiltration with a local anesthetic at the point of interest can be helpful to further optimize treatment. 
In a series of 12 patients, Weber and Lochner349 reported minor restrictions in range of motion in all patients. Residual disability was noted in 75%, with pain laterally in 25%. Following dislocation of fracture–dislocation of the midtarsal joint, persistent pain and gait disturbances have been reported after both nonoperative84,318 and operative treatment.153,335 With articular involvement pain can be relate to the CC joint.150 In nutcracker-type fractures, nonoperative treatment can lead to asymptomatic patients and also fusion can result in full recovery.142 In isolated cuboid fractures satisfactory clinical results can be found with ORIF,295 but greater discomfort was seen in crush and medial column injuries.349 Pain free long-term outcome has been reported following reduction of an isolated CC dislocation,176 and return to normal foot function is not an uncommon finding.94 
Most often complications are attributable to implants and can lead to secondary intervention. Secondary arthrodesis of the midfoot is usually preferred to treat symptomatic flatfoot deformity. Richter et al.289 reported 34 surgical revision procedures, and Schildhauer et al.308 described hardware irritation related to implants in two patients. Tountas et al.335 reported cuboid fracture healing with shortening. Rates of 17% and 18% for pes planus and pes cavus deformities, respectively has been reported following cuboid fracture care.72 Post-traumatic osteoarthritis is a major contributor to disability following cuboid fracture. Early onset of arthritis has been reported following cuboid fractures349 and midfoot injuries.153 Weber and Lochner349 recorded an incidence of 25% of early-onset osteoarthritis in patients with joint involvement. Others have noted high rates of arthritis following combined midfoot fracture/dislocation injuries.289 In one series, midtarsal subluxation with CC joint compromise, 80% of the patients developed arthritis.150 

Author’s Preferred Treatment

 
 

Stable, nondisplaced cuboid fractures and avulsion fractures without instability or associated injuries to the forefoot or midfoot are treated primarily conservatively with immobilization in a walking cast for 6 to 8 weeks. Dynamic fluoroscopy or standing weight-bearing radiographs are performed when there is concern regarding stability. The stability of each column always requires evaluation and determines the treatment algorithm. If operative treatment is indicated, risks and common complications need to be outlined to the patient and final decision is left to the discretion of the patient.

 

Over the years and with increasing understanding of the importance of the integrity of the longitudinal, as well as the transverse functional anatomy of the tarsal osseous complex, treatment strategies have shifted to a more aggressive approach. The goal is the restoration of articular congruence, column length, and capsulo-ligamentous stability. CT imaging and dynamic fluoroscopy will guide treatment. If the fracture is nondisplaced, but there is apparent ligamentous instability, a closed fixation technique is recommended using 1.6- or 2.0-mm K-wires introduced in a retrograde fashion from the base of the fourth and fifth metatarsals into the cuboid and the lateral cuneiform. Also temporary CC transfixation is optional. As an alternative, the lateral column can be spanned using an external fixator (Fig. 62-16).

 
Figure 62-16
Treatment of a cuboid fracture associated with lateral tarso-metatarsal joint instability by external fixation in a multiple injured patient.
Rockwood-ch062-image016.png
View Original | Slide (.ppt)
X
 

Simple fractures in the coronal or longitudinal plane can be fixed using 2.7- or 3.5-mm screws. These are applied using a lag technique perpendicular to the fracture plane. However, screw fixation alone remains a rare treatment option, as the thin lateral cortex is prone to collapse. This technique should be performed only when good bone stock is present. In general, we prefer plate fixation as it provides a more stable construct, and thus, increased stability. Even with simple fracture patterns, open reduction is preferred over closed treatment as assessment and control of anatomic articular reconstruction via image intensification can be tricky due to the curvature of the articular surface. Closed reduction and internal screw fixation should be reserved for the patient with a compromised soft tissue envelope.

 

If associated injuries of the foot require surgical intervention, we recommend also addressing the minimally displaced cuboid fracture to increase midfoot stability. Especially with the severely damaged medial tarsal column, the cuboid will serve as the basis for reconstruction of medial column alignment. Articular surface displacement of more than 1 mm is, in our hands, an indication for operative fixation. An attempt should be made to reduce the cuboid by ligamentotaxis and application of a pointed reduction clamp. If reduction cannot be obtained or maintained, open reduction and fixation is required. All compression type fractures result in lateral column shortening, which will compromise patient satisfaction in the long run. These fractures require restoration of cuboid length, and, in most cases, an autologous bone graft is necessary to fill the defect.

 

Usually we place the patient in a supine position on a translucent fracture table using a bolster or wedge under the hip to rotate the injured leg into a neutral position. The leg is elevated and exsanguinated, and a tourniquet is inflated. The skin incision is centered straight over the cuboid and between the bases of the fourth and fifth metatarsals. The peroneal tendons and sural nerve are identified and protected. Usually, a mini-fragment fixator is placed along the lateral column to restore length, but also to increase visibility during articular reconstruction. We place one or two pins in the tuberosity of the calcaneus and an additional pin into the base of the fifth metatarsal. Articular compromise is addressed as necessary and with severely damaged surfaces the adjacent bone can be used as a template. Use a smooth lever to press the main fragments against the adjacent intact articular surface. Also, smooth K-wires can be used as joysticks to maneuver major segments into place. Bony defects should be filled with graft. Place the lateral cortex into its original position and buttress the lateral wall with a plate. Preformed mini-fragment plates with 2.0- or 2.7-mm screws can be used to secure bicortical fixation. If instability of the lateral column is obvious on dynamic examination we add internal spanning fixation. Internal spanning fixation can be applied proximally, distally, or both. We usually use 2.7-mm small-fragment reconstruction plates to bridge these joints. As discussed in navicular fracture treatment, screw placement from the cuboid into the navicular or the cuneiform complex should be avoided to prevent interfering with the mobile interplay between the medial and lateral columns of the foot. Primary fusion is only performed in the case of the most severe crush injuries when reconstruction is not possible at all. Most often, we opt for secondary fusion after initial reconstruction of the cuboid.

 

Cuboid dislocation can be regarded as a rarity, though it does occur in some severe TMT fracture–dislocations. In these cases, manual axial traction on the toes of the lateral column combined with slight pressure with the thumb will usually enable reduction. If closed reduction cannot be achieved, open reduction with direct visualization will be required bearing in mind that reduction can be obstructed by interposition of the peroneal tendons.91 In the severely crushed foot an associated compartment syndrome is a common finding and requires immediate intervention. In these cases open reduction should be performed to stabilize and anatomically restore the lateral column. We routinely transfix the lateral TMT complex with 1.25- or 1.6-mm K-wires that are left until ligamentous healing for 6 to 8 weeks (Fig. 62-17).

 
Figure 62-17
Treatment algorithm in cuboid fracture care.
 
CF, cuboid fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
CF, cuboid fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
View Original | Slide (.ppt)
Figure 62-17
Treatment algorithm in cuboid fracture care.
CF, cuboid fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
CF, cuboid fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
View Original | Slide (.ppt)
X

Cuneiform Fractures

Isolated injuries, fractures and/or dislocations, of one or more of the three cuneiform bones are rare. The first reports in the English literature originate from the beginning of the 20th century36,63 and within the current relevant literature evidence is based on small cohorts or case reports.5,28,124,145,220,248,249,309,325 With the modern understanding of functional foot anatomy and improvements in radiographic analysis only few can be regarded in retrospect as true isolated injuries.124,255,260,325 Similar to other tarsal injuries, nondisplaced or minimally displaced cuneiform fractures can be easily missed or the diagnosis can be delayed.124,325 Due to the interposition of the cuneiform bone complex between the Chopart and the TMT joint complexes in the axial plane and their static positioning within the medial column of the foot between the tarsal navicular and the bases of metatarsals 1, 2, and 3 in the sagittal plane, injuries to the cuneiform bones are commonly seen in association with other midfoot injuries.8,47,60,74,92,162,163 Similar to other midfoot fractures such as the cuboid, cuneiform fracture occurrence cannot be sufficiently supported by epidemiologic data. The incidence can be estimated to range from 0.1% to 0.5% of all fractures based on previous epidemiologic data on fracture incidence within the adult industrial population.76 Also stress fractures have been described.51 In military personnel an incidence of 5% to 10% of midfoot pathologies has been reported detected by MR imaging. Conservative treatment,124,255,325 such as closed reduction and plaster cast immobilization techniques,63 and a diversity of surgical fixation techniques have been described including K-wire,145,309 screw,124,260 and plate fixation.13 Also, selected arthrodesis in association with severe patterns of Lisfranc fracture–dislocations and navicular fractures is sometimes an option121 (Fig. 62-18). 
Figure 62-18
Unstable medial cuneiform fracture with associated nondisplaced fractures of the navicular, intermediate cuneiform, and anterior process of the calcaneus in a 70-year-old woman after missing a step.
 
A: Computed tomography with axial reconstructions at the time of injury. B: intraoperative AP view after closed reduction and percutaneous K-wire fixation of the medial column of the foot and open fasciotomy to treat an acute compartment syndrome. C: Intraoperative oblique view of the tarsus. D: Lateral view of the foot.
A: Computed tomography with axial reconstructions at the time of injury. B: intraoperative AP view after closed reduction and percutaneous K-wire fixation of the medial column of the foot and open fasciotomy to treat an acute compartment syndrome. C: Intraoperative oblique view of the tarsus. D: Lateral view of the foot.
View Original | Slide (.ppt)
Figure 62-18
Unstable medial cuneiform fracture with associated nondisplaced fractures of the navicular, intermediate cuneiform, and anterior process of the calcaneus in a 70-year-old woman after missing a step.
A: Computed tomography with axial reconstructions at the time of injury. B: intraoperative AP view after closed reduction and percutaneous K-wire fixation of the medial column of the foot and open fasciotomy to treat an acute compartment syndrome. C: Intraoperative oblique view of the tarsus. D: Lateral view of the foot.
A: Computed tomography with axial reconstructions at the time of injury. B: intraoperative AP view after closed reduction and percutaneous K-wire fixation of the medial column of the foot and open fasciotomy to treat an acute compartment syndrome. C: Intraoperative oblique view of the tarsus. D: Lateral view of the foot.
View Original | Slide (.ppt)
X

Pathoanatomy and Applied Anatomy Relating to Cuneiform Injuries

The three cuneiform bones form the osseous intersection between the longitudinal and transverse arches of the foot with the apex formed by the intermediate cuneiform. They are positioned between the medial ray of the metatarsals distally, the cuboid laterally, and the tarsal navicular proximally.302 The articular surfaces show variation with respect to complete, incomplete, or rudimentary structural modeling.265 This might not only involve main body composition and accessory elements, but also the development of coalitions. The medial, or first cuneiform, has five surfaces – anterior, medial, posterior, lateral, inferior – and a dorsal crest.302 The lateral surface has a bony eminence on its anterior-inferior aspect for the insertion of the strong cuneo1-metatarsal2-ligament (Lisfranc ligament). Furthermore, the peroneus longus tendon inserts onto the anterolateral half of the plantar surface, while the tibialis anterior tendon attaches to the inferior-posterior margin of the medial surface. The intermediate, or second cuneiform, is the smallest and inversely wedge shaped compared to the medial. Five surfaces and a plantar crest are present. The crest is covered by the two other cuneiforms and gives attachment to strong plantar ligaments and the tibialis posterior tendon.302 Pfitzner265 described only a few structural variations for the intermediate cuneiform. In contrast, the lateral, or third cuneiform, shows significant variation, especially of the plantar crest, including formation of the so-called uncinate process on its anteriorplantar aspect.265 Also, variations of the five surfaces265 and coalitions have been reported.302 In addition to various ligamentous insertions, the inferior crest is also the attachment of the tibialis posterior tendon, the oblique head of the adductor hallucis, and the lateral limb of the flexor hallucis brevis.265 

Cuneiform Injury Mechanisms

The amount and direction of force transmission during axial loading is an important factor in determining injury patterns of the cuneiform bones. Most commonly a dorsal dislocation pattern is seen5,92,194 but also plantar displacement has been reported.248,249 With the forefoot dorsiflexed, compressive forces can be transmitted via the distal tarsal osseous scaffold leading to comminution associated with shortening of the medial column. Also with medial cuneiform dislocation shortening of the medial column of the foot has been observed.149 Nashi et al.248 outlined the mechanical properties of the cuneiform osseous scaffold during plantar-flexion force resulting in dorsal displacement of the intermediate cuneiform. 
For isolated medial cuneiform injuries a predominance of direct force transmission have been reported to lead to subtle fractures.124 Khatri and Biggs172 presented a case of direct force transmitted to the tarsus via a pick axe resulting in plantar dislocation of the intermediate cuneiform. Intraoperative evaluation showed osseo-ligamentous stability following reduction. However, most cuneiform injuries occur in association with a TMT or Chopart joint injuries. Hence, axial loading or a twisting force applied to the plantar flexed foot is commonly seen.355 Also, dorsiflexion with acute axial loading, as seen in motor vehicle accidents, can cause fractures and fracture–dislocations.28 Whiley355 distinguished direct and indirect injury mechanisms in 20 TMT injuries. Direct force transmission was seen in crushing injuries resulting in varying degrees of dislocation and fracture patterns. Indirect injury mechanism were more commonly seen and resulted from violent forefoot abduction, plantar flexion of the forefoot, or from a combination of forces. Abduction type TMT injuries were characterized by associated cuboid and second metatarsal base fractures. In experimental studies on cadaver specimens abducting the forefoot with a fixed hindfoot also resulted in this injury type.355 

Diagnosis of Cuneiform Injuries

Comparable to other tarsal injuries swelling, tenderness on palpation, and functional impairment (e.g., trouble-free weight bearing, walking tiptoe) are common clinical findings following cuneiform injuries. As seen in TMT injury,290 ecchymosis and bruising of the plantar and dorsal tarsal areas should always raise suspicion for a tarsal injury. 
Physical examination and a detailed history (mechanism of injury, onset) are supplemented by standardized plain radiographic imaging in AP, oblique (in 30-degree inward rotation),28 and strict lateral projections to improve diagnostic accuracy.16,41,112,243,245,252,279,312 In subtle injuries, a delay in diagnosis occurs commonly.255,325 If a fracture is questionable on plain radiograph CT imaging is recommended to exclude all reasonable doubt.124 As in TMT injuries, the dynamic fluoroscopic examination under anesthesia is an asset to detect malalignment and ligamentous and/or fracture instability. Weight-bearing imaging helps to visualize and discriminate instability of subtle ligamentous injuries from simple sprains. An average of 2.5 mm has been identified as the normal distance between the first and second metatarsal bases in healthy adults.68 The “gap sign,” an increase of the intercuneiform distance, is pathognomic for rupture of the Lisfranc ligament, and thus, intercuneiform instability.80 Determination of tarsal alignment requires evaluation of the anatomic positioning between the tarsal and metatarsal bones. In the normal adult foot the lateral border of the first cuneiform is congruent with the lateral border of the base of the first metatarsal. The medial borders of the second metatarsal base and the adjacent second cuneiform are congruent. The alignment between the medial borders of the lateral cuneiform and the third metatarsal can only be evaluated sufficiently on the oblique radiographic projection. Malalignment of 1 mm or more has been characterized as pathologic.181 Stability of the medial tarsal column can be assessed by using an ab-/adduction stress maneuver.68,244 Because the extent of the injury can be misinterpreted using standard radiographic imaging,147 some have proposed a modifiction of the standard radiographic imaging technique using a dorso-plantar projection combined with 30-degree caudal angulation and 15-degree elevation of the medial border of the foot to increase sensitivity of fracture detection of the first/second cuneiform and medial TMT joint complex.322 If there is clinical suspicion of a tarsal injury that cannot be identified by conventional radiography computed tomography is recommended to facilitate evaluation of injury severity, determination of associated injuries of the foot, and improve treatment stratification. 
Care needs to be taken to distinguish a medial cuneiform fracture from a bipartite cuneiform pattern. A common finding in acute fractures is the coronal orientation of the cleavage plane in medial cuneiform fractures. In contrast, magnetic resonance imaging techniques have demonstrated the bipartite medial cuneiform cleavage pattern to be horizontal in contrast to that of the medial cuneiform fracture.103 Furthermore, Wang et al.346 have also described high-resolution sonography as a valid adjunct in the detection of occult fractures of the foot identifying cortical discontinuity in 24 out of 268 patients, indicating nondisplaced fractures. 
Using MR imaging techniques others251 have reported an incidence of 9.5%, 6.9%, and 4.5% for medial, intermediate, and lateral cuneiform bone stress injuries in military personal, respectively. Cuneiform stress injuries were noted to occur more often in multiple bone stress injuries of the foot compared to isolated injuries (p < 0.05). 

Classification of Cuneiform Injuries

Due to the rare incidence of cuneiform fractures there is a lack of evidence regarding fracture specific variables as a determinant of treatment or functional outcome after cuneiform fracture or dislocation. The most recent OTA classification system with regard to injuries of the foot205 has been significantly condensed and distinguishes only between noncomminuted (85-A) and comminuted (85-B) fracture patterns, which might be an oversimplification. The alphanumeric code further subdivides medial (1), intermediate (2), and lateral (3) cuneiform involvement (Fig. 62-19). Depending on the area and joint involved, OTA codes midfoot dislocation injuries of the foot as 80-C.204 Subgroups include naviculo-cuneiform (80-C3), intercuneiform (80-C4), tarsal-metatarsal (80-C5), and multiple midfoot dislocations (80-C9) (Fig. 62-20). With respect to the medial TMT joint complex first to third TMT joint dislocations are coded as 80-C5.1–3. However, coding of direction- dependent dislocation is not included. Also, isolated or complete cuneiform dislocation, as reported in the literature, is not represented in this classification scheme, and has been subsumed under the alphanumeric 80-C9, multiple midfoot dislocations. Finally, crush injuries of the midfoot region including multiple foot fractures deserved a specific code and are classified as 89-B. 
Figure 62-19
OTA classification of cuneiform fractures.
 
To designate the cuneiform involved, a number corresponding to that cuneiform is placed in parentheses between the anatomic designation and the fracture designation: 85 (x) – where x equals 1 for medial, 2 for middle, and 3 for lateral. Type A designates a simple fracture and Type B denotes comminution.
To designate the cuneiform involved, a number corresponding to that cuneiform is placed in parentheses between the anatomic designation and the fracture designation: 85 (x) – where x equals 1 for medial, 2 for middle, and 3 for lateral. Type A designates a simple fracture and Type B denotes comminution.
View Original | Slide (.ppt)
Figure 62-19
OTA classification of cuneiform fractures.
To designate the cuneiform involved, a number corresponding to that cuneiform is placed in parentheses between the anatomic designation and the fracture designation: 85 (x) – where x equals 1 for medial, 2 for middle, and 3 for lateral. Type A designates a simple fracture and Type B denotes comminution.
To designate the cuneiform involved, a number corresponding to that cuneiform is placed in parentheses between the anatomic designation and the fracture designation: 85 (x) – where x equals 1 for medial, 2 for middle, and 3 for lateral. Type A designates a simple fracture and Type B denotes comminution.
View Original | Slide (.ppt)
X
Figure 62-20
OTA classification for cuneiform dislocations (80-C).
 
A: The designation for intercuneiform joint disruption. B: The designation for naviculocuneiform dislocations.
A: The designation for intercuneiform joint disruption. B: The designation for naviculocuneiform dislocations.
View Original | Slide (.ppt)
Figure 62-20
OTA classification for cuneiform dislocations (80-C).
A: The designation for intercuneiform joint disruption. B: The designation for naviculocuneiform dislocations.
A: The designation for intercuneiform joint disruption. B: The designation for naviculocuneiform dislocations.
View Original | Slide (.ppt)
X

Cuneiform Injury Treatment Options

In general, treatment of cuneiform injuries should be based not on the pattern of the fracture but rather on the presence of instability or shortening. Similar to other midfoot injuries, cuneiform fractures, if displaced, require aggressive surgical treatment as column instability, articular incongruity, and column dimensions require restoration of the transverse and longitudinal anatomy of the midfoot. As first reported by Clark and Quint,63 in fracture–dislocations of the cuneiforms closed reduction and plaster cast immobilization was associated with recurrent displacement due to persistent instability and open reduction was necessary. Recently Guler et al.124 reported two cases of isolated medial cuneiform fractures, one treated with cast immobilization for 6 weeks and one with surgical fixation. Both patients returned to a full level of activity at 4 to 6 months. 
Nonoperative Treatment.
Despite some previous reports of successful nonoperative treatment of cuneiform dislocation patterns by closed reduction and plaster cast immobilization techniques, others28,248 have shown that persistent instability creates the risk of redislocation. Furthermore, anterior tibial tendon interposition can make a closed reduction impossible.149 However, effective nonoperative treatment with cast immobilization for 6 weeks in nondisplaced cuneiform fractures has been reported.124,248 
Nonoperative treatment can be pursued if articular displacement is less than 2 mm. A dislocation pattern and/or medial column instability usually are contraindications to nonoperative treatment. The treatment of choice is immobilization in a short-leg cast with non-weight-bearing for 6 to 8 weeks. The role of removable walkers is not known. 
Caution is required in patients with apparently trivial nondisplaced fractures of the cuneiform complex. Due to the stable anatomic configuration of the medial tarsal complex these injuries require a great amount of force and thus, only in a minority are truely isolated injuries. In our hands all tarsal fractures undergo weight-bearing radiographs or dynamic fluoroscopic examination under anesthesia. Using these evaluations, the surgeon will be able to exclude fracture and ligamentous instability within the midtarsal complex. Close follow-up is warranted if nonoperative treatment is selected since secondary dislocation is a common complication. 
Operative Treatment of Cuneiform Injuries.
Closed reduction facilitated by skeletal traction has been reported as an option in the treatment of tarsal fracture–dislocations.149 In some cases, interposition of the anterior tibial tendon can interfere with reduction and necessitate an open approach.66 If closed reduction restores normal anatomy, minimally invasive fixation, such as percutaneous pin (1.6- or 2.0-mm) or screw (2.7- or 3.5-mm) fixation, can be used to maintain the reduction and column length.194 Hidalgo et al.145 reported healing and good functional results after closed reduction and K-wire fixation of a medial cuneiform fracture–dislocation. However, when there is persistent joint instability within the tarsal complex or anatomic realignment cannot be reestablished, open reduction should be performed. Khatri and Briggs172 reported a case of isolated intermediate cuneiform dislocation treated with minimal-invasive reduction and cast immobilization for 6 weeks. At surgery, a blunt dissector was introduced to lever the cuneiform back into place. Subsequently, the tarsus was found to be stable during stress examination. The patient had returned to his previous level of work and was pain free at 12 months of follow-up. 
Following reduction, transfixation to the adjacent osseous structures (navicular, cuneiform, metatarsal) should be employed to improve stability. However, fixation to the cuboid (thus crossing the columns of the foot and interfering with independent column mobility) should be avoided. Even with the severe trans-cuneiform fracture–dislocation pattern a good functional outcome can be achieved if medial column alignment and anatomic reduction of the medial and transverse arch have been reestablished.220 In many cases of reconstruction of the osseous anatomy, bone voids are left that require graft augmentation which can be obtained from the calcaneus or the distal tibia. Postoperatively, the patient is kept non-weight-bearing for 6 weeks in a below-knee cast or removable walker (for the reliable patient). At 6 weeks after surgery47,248 the K-wires can be usually safely removed. 

Management of Expected Adverse Outcomes and Unexpected Complications

To date reports on complications linked to the treatment of cuneiform injuries are rare. Secondary dislocation after nonoperative treatment has been reported necessitating conversion to operative fixation.124 Others have reported the persistence of pain47,63 and limp, or impaired tarsal joint movement.149 The presence of longitudinal arch collapse,149 the need to wear orthotics,63 and the development of nonunion49 have also been reported. Although osteonecrosis is an assumable complication following dislocation, Nishi et al.249 observed complete osseous integrity after intermediate cuneiform dislocation after 2 years of follow-up. 

Author’s Preferred Treatment

 
 

As we see a large number of high-energy injuries in our practice, high-injury severity and the presence of associated osseo-ligamentous injuries are common findings. Therefore, we favor an aggressive treatment regimen when confronted with cuneiform injuries. When a fracture is nondisplaced, ligamentous instability and the presence of associated foot injuries must be excluded. Only truly isolated injuries with a stable tarsus will be treated with cast immobilization for 6 weeks.

 

If closed reduction is required to restore the anatomy it is usually combined with percutaneous K-wire (1.6 to 2.0 mm), or preferably, 2.7-mm screw fixation to secure the construct (Fig. 62-21).

 
Figure 62-21
 
Closed reduction and internal fixation using 2.0-mm K-wires of an unstable intermediate cuneiform fracture–dislocation in a 52-year-old construction worker after a crush injury of the right foot. A: AP view showing widening of the intercuneiform space (arrow 1) and shortening of the second MT (arrow 2). B: lateral view showing a dorsally displaced, unstable fracture–dislocation of the intermediate cuneiform. C: postoperative AP radiograph following closed reduction and pinning the TMT/cuneiform injury and temporary ankle spanning external fixator application. D: postoperative oblique radiograph.
Closed reduction and internal fixation using 2.0-mm K-wires of an unstable intermediate cuneiform fracture–dislocation in a 52-year-old construction worker after a crush injury of the right foot. A: AP view showing widening of the intercuneiform space (arrow 1) and shortening of the second MT (arrow 2). B: lateral view showing a dorsally displaced, unstable fracture–dislocation of the intermediate cuneiform. C: postoperative AP radiograph following closed reduction and pinning the TMT/cuneiform injury and temporary ankle spanning external fixator application. D: postoperative oblique radiograph.
View Original | Slide (.ppt)
Closed reduction and internal fixation using 2.0-mm K-wires of an unstable intermediate cuneiform fracture–dislocation in a 52-year-old construction worker after a crush injury of the right foot. A: AP view showing widening of the intercuneiform space (arrow 1) and shortening of the second MT (arrow 2). B: lateral view showing a dorsally displaced, unstable fracture–dislocation of the intermediate cuneiform. C: postoperative AP radiograph following closed reduction and pinning the TMT/cuneiform injury and temporary ankle spanning external fixator application. D: postoperative oblique radiograph.
View Original | Slide (.ppt)
Figure 62-21
Closed reduction and internal fixation using 2.0-mm K-wires of an unstable intermediate cuneiform fracture–dislocation in a 52-year-old construction worker after a crush injury of the right foot. A: AP view showing widening of the intercuneiform space (arrow 1) and shortening of the second MT (arrow 2). B: lateral view showing a dorsally displaced, unstable fracture–dislocation of the intermediate cuneiform. C: postoperative AP radiograph following closed reduction and pinning the TMT/cuneiform injury and temporary ankle spanning external fixator application. D: postoperative oblique radiograph.
Closed reduction and internal fixation using 2.0-mm K-wires of an unstable intermediate cuneiform fracture–dislocation in a 52-year-old construction worker after a crush injury of the right foot. A: AP view showing widening of the intercuneiform space (arrow 1) and shortening of the second MT (arrow 2). B: lateral view showing a dorsally displaced, unstable fracture–dislocation of the intermediate cuneiform. C: postoperative AP radiograph following closed reduction and pinning the TMT/cuneiform injury and temporary ankle spanning external fixator application. D: postoperative oblique radiograph.
View Original | Slide (.ppt)
Closed reduction and internal fixation using 2.0-mm K-wires of an unstable intermediate cuneiform fracture–dislocation in a 52-year-old construction worker after a crush injury of the right foot. A: AP view showing widening of the intercuneiform space (arrow 1) and shortening of the second MT (arrow 2). B: lateral view showing a dorsally displaced, unstable fracture–dislocation of the intermediate cuneiform. C: postoperative AP radiograph following closed reduction and pinning the TMT/cuneiform injury and temporary ankle spanning external fixator application. D: postoperative oblique radiograph.
View Original | Slide (.ppt)
X
 

As in tarsal navicular and cuboid fracture treatment, associated osseous and ligamentous instability and deformity is best addressed using an open reduction technique with rigid fixation. A dorsal approach for the cuneiform is performed as in the treatment of medial TMT complex injuries. The neurovascular bundle is identified and protected during dissection to the cuneiform of interest. The tibialis anterior tendon is identified and freed if interposed. Column length and articular congruity are restored. In some cases a temporary spanning external fixator can be introduced into the base of the first metatarsal and the body of the talus or distal tibia to distract the medial column. If required for osseous reconstruction, autologous bone graft can be obtained from the calcaneus or distal tibia. The degree of joint damage should be carefully assessed. With high-injury severity, partial fusion is recommended. Screw and plate fixation can provide sufficient stability. When opting for plate fixation, 2.7-mm reconstruction or 1/3- to 1/4-tubular plates are usually used. To increase the stability of cuneiform fixation, screw positioning can include metatarso-cuneiform, intercuneiform, or naviculo-cuneiform transfixation, respectively. Typically, we start with intercuneiform transfixation in a medial to lateral direction using 2.7-mm cortical screws to create a stable medial tarsal block. We usually create a trough and countersink the head of the screw. This avoids prominence and prevents cortical avulsion when introducing the screw in an inclined fashion. Large fragments require screw fixation to the metatarsal base or navicular. Also, medial tarsal bridge plating as described above can be used to achieve and maintain medial column stability with good functional results.308 Cuneiform fractures usually require a higher amount of energy, thus, soft tissue injury and compromise are common findings. Be vigilant for an associated compartment syndrome, which needs to be addressed promptly. Following reduction and fixation, the patient is keep non-weight-bearing for 6 weeks following partial weight bearing for another 4 weeks.

Tarsometatarsal (Lisfranc Joint) Injuries

Acute injuries to the TMT or Lisfranc joint are rare accounting for 0.1% to 0.4% of all fractures and dislocations.76 Despite improvements in diagnosis, missed or overlooked injuries are common. Especially the isolated pure ligamentous TMT instability is misdiagnosed in up to 20%.118,279,315 Insufficient treatment can lead to painful secondary deformity and impaired function.56,239,245,280 While, nonoperative treatment has been linked to an increased incidence of secondary displacement and inferior functional outcome,16,245 primary open reduction and internal fixation has become the preferred method of treatment when there is structural ligamentous instability or fracture–dislocation.16,141,163,181,243,308,330 Surgical reconstruction cannot only reestablish normal gait biomechanics, but we believe it also prevents secondary arthritis and improves functional outcome. The key factors are restoration of anatomical alignment and articular congruity. Patients sustaining TMT injuries are often confronted with a prolonged convalescence, thus, these injuries jeopardize full social, athletic, and professional reintegration. Therefore, TMT injuries are demanding injuries for the patient and remain challenging even for the experienced orthopedic surgeon. 
Historically the importance of the TMT joint line has been attributed to the French gynecologist and Napoleonic surgeon Jacques L. Lisfranc. He was the first to describe an amputation technique through the TMT joint line, as well as, the plantar ligamentous connections of the first and second TMT joints. However, acute injuries of the TMT joint complex such as fracture–dislocations were not delineated by Lisfranc.272 The first descriptions of these injuries can be found in the European literature at the beginning of the 19th century including a detailed analysis of TMT injuries based on clinical observations and anatomical investigations by Quénu und Küss.41,272 Also, Böhler41 delineated one of the first treatment algorithms. More recently, a number of well-designed studies have been published forming the evidence for treatment algorithms found in the current orthopedic literature.131,163,216,237 

Pathoanatomy and Applied Anatomy Relating to Tarso-Metatarsal Injuries

Appreciation of the functional anatomy of the complex aggregate of osseous and ligamentous structures forming this joint is imperative to provide an adequate assessment and treatment of Lisfranc fracture–dislocations. The TMT joint complex forms the distal limit between the tarsal and metatarsal units. The osseous tarsal complex is comprised of the navicular, the cuboid, and the three cuneiform bones. Due to its positioning, resulting from a relative short intermedial cuneiform and sandwiched between the adjacent medial and lateral cuneiforms, the second metatarsal has been recognized as the keystone within this osseous scaffold. This architectural characteristic accounts for substantial bony stability. The cuboid is the keystone in the lateral column of the foot articulating with the calcaneus and the bases of the fourth and fifth metatarsals in the axial plane, and the navicular and the lateral cuneiform in the coronal plane.179 Similarly, the navicular forms the key in the medial column. Some authors have described the TMT joint complex as a three column system: the medial column (first TMT joint), the intermediate column (second/third TMT joints), and the lateral column (fourth/fifth TMT joints).177 
The cuneiform bones are part of the transverse arch, a tarsal architectural characteristic simulating a Roman arch that acts as a niche for the plantar musculotendinous and neurovascular structures.303 
The longitudinal arch is a dorso-convex bow spanning from the head of the metatarsals to the calcaneus,179 which is stabilized by the plantar aponeurosis, the long plantar ligament, and the peroneus longus tendon.179 A multiplicity of dorsal and plantar ligamentous connections results in an amphiarthrotic interface of tarsal and metatarsal bones, especially during phases of stance.301 Out of these, the so-called “Lisfranc ligament bundle,” spanning from the first cuneiform to the second metatarsal,272 as well as the pC1-M2M3 ligament,167 connecting the plantar aspect of the medial cuneiform to the bases of the second and third metatarsals, provide substantial stability to the TMT joint line. In a biomechanical analysis load to failure and stiffness were more than two times greater for the Lisfranc ligament than for the dorsal ligament connecting the medial cuneiform and base of the second metatarsal.182 Both ligamentous structures were felt to be important stabilizers of the medial TMT column, however, the more commonly found dorsal displacement is related to the lower load to failure of the dorsal ligament. In addition to the osseous and ligamentous structural support, the TMT line is further stabilized by surrounding muscles. The osseous components of the Lisfranc complex are subjected to compressive stresses during load, which results in the formation of the characteristic spongy architecture.179 The dorso-plantar joint diameter of the first TMT joint is about 3 cm,131 and biomechanical analysis has demonstrated a significant amount of motion in both the first and fifth TMT joints.143,257 

Tarso-Metatarsal Injury Mechanisms

In Europe, Lisfranc fracture–dislocations occur with an incidence of 1 per 60,000 population per year and an unimodal distribution characterizes an age-specific maximum for young males followed by young females.135 In contrast, a sport-specific incidence rate of 0.3% to 6.2% has been demonstrated in athletes.77 
Injury mechanisms are manifold and may result from both direct and indirect forces.243,245 Crush injuries create a great variety of fracture and dislocation patterns, and are usually associated with a substantial amount of soft tissue damage.246 A compartment syndrome is frequently associated with a crush injury and requires prompt attention. Indirect injury, most often axial loading, follows the longitudinal column of the foot, and subjects it to rotational, bending and compressive forces.244 When axially loaded, a plantar flexed foot sustains rupture first of the weaker dorsal ligamentous structures. The fracture–dislocation becomes complete if the proximal metatarsals fracture and/or the stronger plantar ligaments rupture. In addition, a dorsal bending moment applied during axial compression of the foot has been shown to lead consecutively to dorsal followed by lateral TMT dislocation.7 Low-energy injury mechanisms, typically during athletic activity, are more subtle in their clinical presentation.131,244 
Road accidents are the cause of more than two-third of these injuries, followed by direct crush injuries and falls from a height.181,245 Injuries resulting from sports, such as soccer, football, and horseback riding, are frequently seen.191,244 Isolated injuries have a reported incidence of about 50%.181 Open fractures are common (approximately 12%).141 Despite our improved understanding of injury mechanisms and better diagnostic testing tools, a high incidence of missed injuries has been demonstrated in the recent literature.315 Associated injuries of the foot, especially of the tarsus, are a frequent finding and should always draw suspicion to a TMT injury.16,141,177,181,245 

Signs, Symptoms, and Imaging

Painful swelling, and functional disability (e.g., inability to perform pain free weight bearing or the inability to stand on tip-toe) are common clinical findings.312 Also, often plantar ecchymosis (Fig. 62-22) is present, and this finding should raise suspicion of a TMT injury.290 In contrast, others have not seen the plantar ecchymosis sign in isolated TMT injuries in athletes.312 Typically, the TMT transition zone will be widened in comparison to the opposite foot.41 
Figure 62-22
Plantar ecchymosis is a common clinical finding associated with a Lisfranc fracture–dislocation.
Rockwood-ch062-image022.png
View Original | Slide (.ppt)
X
With regard to diagnostic testing, Myerson and Cerrato244 described the abduction–pronation maneuver, comparable to an apprehension test, and the transverse TMT-1/2 squeeze test as subtle but useful clinical tools (Fig. 62-23). 
Figure 62-23
Clinical tests used to identify a TMT joint injury.
 
Left: The TMT squeeze test. Right: The abduction-pronation maneuver.
Left: The TMT squeeze test. Right: The abduction-pronation maneuver.
View Original | Slide (.ppt)
Figure 62-23
Clinical tests used to identify a TMT joint injury.
Left: The TMT squeeze test. Right: The abduction-pronation maneuver.
Left: The TMT squeeze test. Right: The abduction-pronation maneuver.
View Original | Slide (.ppt)
X
A detailed history (mechanism of injury, onset) and a discerning clinical examination are supplemented with standardized radiographic imaging to increase sensitivity and specificity, and confirm the diagnosis. AP, oblique (in 30-degree internal rotation), and true lateral projections are obtained routinely.16,41,112,243,245,252,279,312 Weight-bearing radiographic imaging is essential to distinguish the instability of subtle ligamentous injuries from simple sprains (Fig. 62-24). The first/second-intermetatarsal base distance in healthy adults on weight-bearing radiographs has been shown to average 2.5 mm (SD: 0.64 mm).68 The “fleck-sign,” an avulsion fracture of the base of the second metatarsal or medial cuneiform, is pathognomic for a Lisfranc injury.245 The normal anatomic TMT alignment should be assessed by evaluating the position of the tarsal bones in relation to the adjacent metatarsals.112,252 In the normal foot the lateral border of the medial cuneiform is in line with the lateral border of the base of the first metatarsal. Furthermore, a colinear relation is present between the medial margin of the base of the second metatarsal and the adjacent intermediate cuneiform. Similarly, the medial border of the base of the fourth metatarsal is in line with the medial border of the cuboid, which can only be assessed sufficiently on the oblique radiographic projection. Malalignment of 1 mm or more has been characterized as pathologic.181 Assessment of the stability of the medial TMT joint line has been described by Coss et al.65 using the abduction stress maneuver. A tangent placed along the medial border of the medial cuneiform should intersect the base of the first metatarsal. In the case of medial TMT instability with forefoot abduction stress this line passes medial to the base (a positive “medial column sign”). In a manner similar to this technique, the ligamentous connections can be evaluated for stability using dynamic radiographic stress testing. Coss et al.68 demonstrated medial column line displacement as a result of incompetence of the Lisfranc ligament combined with the dorsal TMT ligament. The positions of the base of the second metatarsal on the AP projection and of the fourth metatarsal on the oblique projection are the key indicators of TMT complex instability. However, we would like to point out the importance of using weight-bearing radiographic studies in this context. Shapiro et al.312 provided evidence for insufficient validity of non-weight-bearing images compared to weight-bearing radiographic image analysis in discriminating stable and unstable TMT injuries (Fig. 62-25). In the case of suspicion for a TMT injury during clinical or radiographic evaluation, we use dynamic fluoroscopy under anesthesia to determine alignment, ligamentous compromise, and fracture stability.68,243 
Figure 62-24
Dynamic imaging under anesthesia of the TMT joint complex to determine ligamentous instability.
 
A: Normal. B: Pathologic. 1, medial column line; 2, widening of the first TMT joint space; 3, subluxation by lateral translation of the base of the first metatarsal. The white circle identifies the “positive medial column sign.”
A: Normal. B: Pathologic. 1, medial column line; 2, widening of the first TMT joint space; 3, subluxation by lateral translation of the base of the first metatarsal. The white circle identifies the “positive medial column sign.”
View Original | Slide (.ppt)
Figure 62-24
Dynamic imaging under anesthesia of the TMT joint complex to determine ligamentous instability.
A: Normal. B: Pathologic. 1, medial column line; 2, widening of the first TMT joint space; 3, subluxation by lateral translation of the base of the first metatarsal. The white circle identifies the “positive medial column sign.”
A: Normal. B: Pathologic. 1, medial column line; 2, widening of the first TMT joint space; 3, subluxation by lateral translation of the base of the first metatarsal. The white circle identifies the “positive medial column sign.”
View Original | Slide (.ppt)
X
Figure 62-25
The use of stress films to identify unstable injuries is important.
 
A: Non-weight-bearing radiograph of midfoot pain. B: A weight-bearing stress view of the same foot showing widening between the first and second rays.
A: Non-weight-bearing radiograph of midfoot pain. B: A weight-bearing stress view of the same foot showing widening between the first and second rays.
View Original | Slide (.ppt)
Figure 62-25
The use of stress films to identify unstable injuries is important.
A: Non-weight-bearing radiograph of midfoot pain. B: A weight-bearing stress view of the same foot showing widening between the first and second rays.
A: Non-weight-bearing radiograph of midfoot pain. B: A weight-bearing stress view of the same foot showing widening between the first and second rays.
View Original | Slide (.ppt)
X
While an associated compartment syndrome has been reported to be uncommon with these injuries,191,279 we recommend the measurement of compartment pressures in the foot when there is pronounced swelling or progressive pain. 
On occasion to evaluate injury severity and associated injuries of the foot, and to optimize treatment stratification computed tomography is used as a supplemental analytic tool.117,127 Raikin et al.274 provided evidence that MR imaging is an effective way to identify TMT instability. In that study, the authors were able to categorize 90% of TMT injuries as either stable or unstable with a sensitivity of 94% and a specificity of 75%. Second metatarsal base avulsion fracture and plantar Lisfranc ligament bundle disruption were found to be predictive for Lisfranc complex instability. 
Since the introduction of MRI into the clinical routine bone scanning has lost importance as a routine diagnostic measure and is reserved for specific questions.123 However, Nunley and Vertullo253 reported a high sensitivity using scintigraphy in conjunction with weight-bearing radiographic imaging for subtle, nondisplaced TMT injuries in athletes. All patients with stage I injuries had a positive bone scan with a median time interval from injury to diagnosis of 2 months (range: 3 days to 8 months). 

Classification of Tarso-Metatarsal Injuries

The most commonly used classification system of Lisfranc fracture–dislocations was introduced into the literature in 1909 by Quénu and Küss.272 It describes three types of injury pattern: Homolateral, isolated, and divergent (Fig. 62-26). Hardcastle et al.135 provided a classification system, a modification of the pathologic-anatomical Quénu-Küss classification, which was based on radiographic morphology. Within it, three main groups were distinguished including complete, partial, and divergent dislocation patterns. Type A (complete) fracture–dislocations are characterized by involvement of all parts of the Lisfranc joint complex with dislocation within one plane (sagittal, frontal, combined). In contrast, Type B (partial) fracture–dislocations are identified by partial incongruity of the joint complex. Similarly, the involved joint complex shows dislocation in the sagittal, frontal, or combined plane. A medial dislocation pattern is distinguished from a lateral pattern. In medial dislocation the first metatarsal or a variable number of metatarsals excluding the fifth will be involved. In a lateral dislocation pattern, one or more of the lateral metatarsals are dislocated, while the first ray remains stable and intact. Finally, in Type C (divergent) fracture–dislocations, complete and partial injury patterns can be seen. In the AP projection, medialization of the first metatarsal in conjunction with lateral translation of a variable number of the lateral four metatarsal bones can be found. 
Figure 62-26
The common classification devised by Quenu and Kuss.272
 
A: Depicts homolateral disruption where all metatarsals travel in the same direction. This group can be subdivided into medial or lateral to denote the direction of disruption. B: Partial disruption involves only the first metatarsal or all the lesser rays. C: Divergent dislocation occurs when there is complete disruption of the tarsometatarsal joints but the first ray and the lesser rays displace in opposite directions.
A: Depicts homolateral disruption where all metatarsals travel in the same direction. This group can be subdivided into medial or lateral to denote the direction of disruption. B: Partial disruption involves only the first metatarsal or all the lesser rays. C: Divergent dislocation occurs when there is complete disruption of the tarsometatarsal joints but the first ray and the lesser rays displace in opposite directions.
View Original | Slide (.ppt)
Figure 62-26
The common classification devised by Quenu and Kuss.272
A: Depicts homolateral disruption where all metatarsals travel in the same direction. This group can be subdivided into medial or lateral to denote the direction of disruption. B: Partial disruption involves only the first metatarsal or all the lesser rays. C: Divergent dislocation occurs when there is complete disruption of the tarsometatarsal joints but the first ray and the lesser rays displace in opposite directions.
A: Depicts homolateral disruption where all metatarsals travel in the same direction. This group can be subdivided into medial or lateral to denote the direction of disruption. B: Partial disruption involves only the first metatarsal or all the lesser rays. C: Divergent dislocation occurs when there is complete disruption of the tarsometatarsal joints but the first ray and the lesser rays displace in opposite directions.
View Original | Slide (.ppt)
X
In 1986, Myerson245 introduced a classification, which in the broadest sense can be considered a modification of the aforementioned systems. However, the Myerson classification incorporates osseous injuries of the medial column of the foot and also differentiates three types of injury pattern. Type A injuries include complete incongruity of the TMT joint line in any plane or direction. A Type B1 injury is determined by partial incongruity involving the first ray (partial–medial incongruity). Dislocation of one or more of the lateral four metatarsal bones characterizes a Type B2 injury pattern, also termed partial-lateral incongruity. A Type C1 (divergent) injury has a diverging injury pattern comprised of medialization of the first ray associated with dislocation and partial incongruity of the lateral metatarsals. A Type C2 injury has a diverging injury pattern with complete incongruity. 
Nunley and Vertullo253 reported a classification system for nondisplaced and displaced TMT sprains in athletes based on weight-bearing radiographic analyses and scintigraphic findings. Stage I injuries were characterized by no displacement at the Lisfranc complex constituting a sprain of the Lisfranc ligament without diastasis or loss of medial column height. These injuries were nondisplaced on weight-bearing radiographs but showed increased uptake on bone scintigrams. Stage II injuries showed diastasis of 1 to 5 mm at the first/second intermetatarsal space, resulting from a rupture of the Lisfranc ligament, but no medial column sag. In contrast, stage III injuries presented with diastasis of the first/second-intermetatarsal space (>5 mm) and loss of medial column height. 
The revised version of the AO/OTA classification system204,205,206,211 distinguishes Lisfranc fracture–dislocations according to the resulting deformity. Hence, a type of dislocation pattern and an associated fracture pattern of the foot can both be described. Pediatric Lisfranc fracture–dislocations are rare259,323 and to date a nongeneric system has not been implemented within trauma. The current classification systems lack evidence regarding their impact in the prediction of treatment or clinical and functional outcomes. Furthermore, we do not believe that pure ligamentous injuries and nondisplaced Lisfranc injury patterns are sufficiently represented in the current systems. 

Treatment Options

Nonoperative Treatment.
Nonoperative treatment of TMT injuries is an option, if instability has been excluded during functional radiographic analysis (stress examination/weight-bearing imaging). When isolated ligamentous injury is present, which most often results from low-energy trauma, and instability, persistent subluxation, or an avulsion fracture has been excluded, the patients’ leg can be immobilized in a below-knee cast with non-weight-bearing restrictions.131,244,245 Nonoperative management includes close clinical and radiographic follow-up, including weight-bearing radiographic analysis every second week. Those TMT injuries that remain stable during follow-up at 6 weeks can be converted from non-weight-bearing to toe-touch weight-bearing restriction in a short-leg cast or boot. The patient is then instructed to start with progressive weight bearing if clinical and radiographic assessment indicate healing and maintenance of reduction, and if the clinical examination shows no residual pain in the midfoot. In conjunction with physical therapy guided rehabilitation including patient directed ROM exercises and customized footwear is provided. Many patients need custom made orthoses, sole stiffeners, or medial arch supports. We believe, that the medial column of the foot requires sufficient support, keeping in mind that the preserved medial longitudinal arch is one key in achieving a superior functional outcome.107 Nunley and Vertullo253 reported excellent results following a nonoperative treatment algorithm for nondisplaced (Stage I) TMT injuries. Professional or athletic activities requiring walking on uneven underground or causing torsional and/or bending force over the tarsus (e.g., climbing ladders, stooping, kneeing, or running) necessitate a period of rest of at least 4 months. This should be taken into account when planning rehabilitation especially in athletes but also following work related injuries. Despite the fact that healing of the ligamentous and osseous complex of the TMT joint can be expected within 3 to 4 months after the injury, work and athletic reintegration can be delayed for 6 to 9 months129,131,253,303,312,345 (Table 62-9). 
 
Table 62-9
Tarso-Metatarsal Injuries
View Large
Table 62-9
Tarso-Metatarsal Injuries
Indications for Nonoperative Treatment
Nondisplaced/pure ligamentous injury
  •  
    malalignment <1 mm
  •  
    articular displacement <2 mm
Intact medial column of the foot (Length/stability)
No major associated midfoot injuries
No vascular or soft tissue compromise
Surgical contraindications
X
Operative Treatment of TMT Injuries.
The indications for surgical treatment are presented in Table 62-10
 
Table 62-10
Tarso-Metatarsal Injury
View Large
Table 62-10
Tarso-Metatarsal Injury
Surgical Treatment
Indications Contraindications
Malalignment ≥1 mm Compromised soft tissue coverage
Articular incongruity >2 mm General health condition of the patient
Soft tissue or bone fragment preventing reduction:
  •  
    avulsion fracture
  •  
    tibialis anterior tendon
  •  
    dorsal / plantar ligaments
Severe arterial vascular disease
Medial column instability or shortening Neuropathy
Associated multiple midfoot injuries Noncompliance
Associated compartment syndrome
Open fracture
X
Reduction and Internal Fixation.
The decision as to what surgical treatment path should be followed is not only influenced by the injury pattern (e.g., morphology of the fracture, associated injuries, and instability) but also by the perioperative and postoperative course244 such as, the time of diagnosis, timing of the operation, surgical technique, implant choice, postoperative management, and rehabilitation. 
In general it seems to be accepted that early surgical treatment facilitates the timely initiation of the rehabilitation phase.244 Swelling and soft tissue compromise are major factors influencing when and what type of surgery to perform. Rammelt et al.279 have shown that after 6 weeks fixed deformity can be expected in missed or insufficiently treated TMT injuries. Others have shown that within the first 6 weeks most often operative reduction and fixation is possible.337 If a deformity becomes fixed, secondary repositioning can be impaired necessitating corrective osteotomy and/or arthrodesis. Therefore, operative treatment should be initiated within 4 to 6 weeks after the injury. In our hands a TMT injury associated with a significant deformity and/or soft tissue compromise undergoes a closed reduction, to restore medial and lateral column alignment, followed by primary external fixation for temporary stabilization until the soft tissues permit open reduction and internal fixation. External fixation can be performed in a pyramidal fashion spanning from the distal tibia to the forefoot and the calcaneus, respectively. Alternatively, spanning external fixation on the medial, lateral, or both columns without inclusion of the ankle joint is an option. 
Reduction and Surgical Approach.
Closed reduction: Depending on the direction of the displacement, axial traction applied to the affected ray combined with mild pressure over the displaced metatarsal base and the simultaneous placement of the surgeon’s thumb on the opposite side of the foot slightly proximal to the injury zone will be required to achieve reduction in the sagittal plane. To address medial or lateral displacement, an additional abduction–adduction maneuver is executed. As the second metatarsal is the keystone within the osseous scaffold of the Lisfranc complex, it needs to be addressed in the most meticulous fashion. Sometimes a “pop” can be felt during reduction, which then should be assessed using fluoroscopy. In many cases the medial and lateral columns will follow the second metatarsal. If all indices of anatomic repositioning (see radiographic alignment criteria above) in all three planes show colinearity, thus, anatomic alignment, dynamic fluoroscopy can provide information regarding the degree of stability. If the reduction is stable and no further major associated injuries of the foot are present, requiring surgical intervention, nonoperative treatment can be initiated (see above). If the reduction is unstable, percutaneous fixation is recommended.16,118,163,239 The ideal choice of implant is still under debate. K-wire placement and screw fixation have been proposed to secure the realigned TMT complex. 
In some cases anatomic reduction cannot be attained by closed means. Incarcerated small avulsion fracture fragments, ligaments–often the Lisfranc ligament, or tendons,19,170 such as the tibialis anterior tendon, need to be removed. 
The most common surgical approach to injuries of the medial column of the TMT complex is a dorsal longitudinal incision in the web space between the first and second metatarsals. Beginning at the mid-diaphysis, the incision continues proximally to the interval between the first and second TMT joints and, if required, it can be extended as far proximally as the talar head. The tendons of the extensor hallucis longus and brevis are identified and retracted by smooth hooks either laterally or medially depending on the part of the TMT complex to be addressed. A full-thickness fasciocutaneous flap is created to protect the vascular and neural bundle. Subperiosteal dissection is used to visualize and reduce the three medial TMT joints. In most cases, but also depending on the direction of displacement, the joint capsule has been torn dorsally. If it is intact, the capsule is incised and the joint is inspected. A thorough joint debridement prevents entrapment of bony and ligamentous residua, which will serve as a reduction barrier. To address the lateral part of the third TMT joint, or if TMT 4/5 requires open reduction, a second surgical incision may be necessary. Leaving a skin bridge of at least 3 cm is mandatory to prevent secondary skin necrosis. The second incision is placed over the fourth metatarsal extending proximally to the cuboid bone. Starting from that incision the surgeon will be able to address the lateral part of TMT 3, as well as TMT 4/5, and the cuboid. The lateral cutaneous branch of the peroneal nerve should be identified and protected. However, in most cases TMT 3 can be easily accessed via the medial approach. Following subperiosteal dissection, the lateral TMT complex is identified and exposed. If the lateral column of the foot is shortened due to cuboid impaction, length and articular congruence are restored using a distractor or a temporary external fixator, which can be left in place as an adjunct during the postoperative phase. 
With restoration of the lateral tarsal column the cuneiform-tarsal complex is reassessed for signs of instability. In many cases the surgeon will find an intercuneiform instability which if addressed first will create a stable tarsal main body. The medial cuneiform is then reduced using a pointed reduction clamp to the intermedial and lateral cuneiforms and fixation is achieved using 2.7-mm cortical screws. Next, the second TMT joint is addressed to achieve an exact anatomic reduction. A pointed reduction clamp is placed on the medial aspect of the medial cuneiform and the lateral cortical wall of the base of the second metatarsal to reduce this keystone in line with the intermediate cuneiform. Hereafter, the first TMT joint is anatomically reduced using a reduction clamp or pointed forceps. 1.6- or 2-mm K-wires are commonly inserted in a retrograde fashion starting with the second TMT joint and proceeding in a medial to lateral direction. The first TMT joint should be stabilized after the other parts of the joint complex have been fixed. A 2.7-mm cortical screw is placed from the proximal medial corner of the medial cuneiform into the base of the second metatarsal (Lisfranc screw). A second screw is then introduced in a retrograde fashion dorsally from the metaphysis of the second metatarsal into the intermediate cuneiform. Countersinking is used to prevent cortical avulsion when the screw head abuts with the cortical bone during compression. Usually the two crossing cortical screws are introduced using a lag screw technique starting with the distal-to-proximal screw. Next, the third TMT joint is reduced and fixed with a distal-to-proximal screw or a 4- or 5-hole ¼-tubular plate. 
In many cases the lateral TMT joint complex will automatically reduce after the medial column has been anatomically reduced and fixed. However, anatomic reduction is mandatory with respect to the fourth and fifth TMT joints. If they do not completely reduce, open reduction is performed via a lateral approach. Fixation is carried out with converging K-wires. Finally, the first metatarsal is reduced and fixed to the second. Beware of rotational deformity when fixing the first ray to the second metatarsal base. Standardized intraoperative radiographic imaging will confirm restoration of alignment and articular congruence. If possible, simulated weight-bearing x-rays should be obtained to visualize persistent malalignment and/or instability. Once sufficiently aligned, rigid TMT transfixation is recommended.131,141,163 In general, the surgical approach will vary depending on the associated ligamentous and osseous injuries, which necessitate supplemental surgical fixation (e.g., cuboid, metatarsals, cuneiforms, tarsal navicular). Some have recommended the use of a transverse approach to the TMT joint complex;343 however, this recommendation is based on a small cohort of only 12 patients. 
The presence of an associated compartment syndrome requires decompression at the beginning of the operative procedure and can be addressed by open fasciotomy using the aforementioned surgical approaches with regard to the dorso-lateral and interosseous compartments.131 The plantar compartments of the foot should be addressed via a separate medial approach plantar to the first metatarsal. The medial fascia of the abductor and flexor hallucis brevis muscles is incised to expose and release the fascia of the flexor digitorum brevis and adductor hallucis. 
The optimal operative strategy—closed, open, or primary arthrodesis—of an unstable Lisfranc fracture–dislocation remains a subject of controversy. There is a lack of strong evidence due to limited cohort size, sample heterogeneity, and a lack of prospective controlled trials.313,320 In a recent Cochrane review by Stavlas et al.320 11 papers were found valid for analysis including 257 patients. Another recent meta-analysis on Lisfranc injury treatment comparing primary arthrodesis with open reduction and internal fixation found only 193 patients valid for inclusion.313 However, in the case of instability operative fixation has become the preferred treatment. While, some authors have reported satisfactory results after closed treatment and temporary pin fixation,7,16,41,135,180,245 more recent publications have shown improved outcomes after more aggressive treatment.6,141,177,181,191,233,275,279,297,327,361 If insufficient reduction and/or significant osseous destruction is present an open approach with rigid fixation is recommended.131,237 A biomechanical analysis in a cadaver study provided evidence for increased stability after rigid screw fixation.285 With placement of the so-called “Lisfranc screw,” which simulates the ruptured ligament in unstable Lisfranc injuries, a mean force to failure of approximately 157 N has been observed.67 In cadaver studies with isolated Lisfranc ligament transection similar stability was observed when comparing screw and suture-button fixation;258,262 however, others have shown advantages of screw fixation when comparing these two techniques.6 
Following exposure of the unstable TMT joint complex, tarsal (tarsal navicular, cuboid, and cuboid bones) instability and incongruity are addressed and temporarily transfixed using K-wires. Reconstruction of anatomic alignment and articular congruence is imperative and requires meticulous surgical precision. Next, if possible, percutaneous intercuneiform and/or naviculo-cuneiform screw fixation—similar to navicular fracture treatment13—is performed to create a stable medial block. Also, an unstable or displaced cuboid requires reconstruction and fixation before addressing the TMT joint complex. In some cases, cuboid-to-cuneiform transfixation is necessary to obviate instability between the two columns of the foot. The keystone of the Lisfranc complex, the second TMT joint, is placed in its anatomic position and is held with a pointed clamp. Step wise radiographic imaging in 3 planes is used to confirm alignment and anatomical reconstruction. For temporary K-wire fixation we prefer retrograde implant placement to prevent secondary displacement while introducing the K-wire. Using dynamic fluoroscopy, definite determination of stability and rigid screw fixation using 3.5-mm low-profile screws is performed in a metatarsal–to–cuneiform direction. In one study, placement of the Lisfranc screw did not show an advantage for either the cuneiform-to-second metatarsal or the second metatarsal-to-cuneiform direction.67 One cadaver study showed similar stability after dorsal bridge-plating compared to screw fixation.9 Whereas screw fixation requires less invasive dissection, plate fixation prevents further articular compromise from screw penetration. If the adjacent lateral TMT complex remains unstable during dynamic fluoroscopy TMT 3 is subject to screw or plate fixation. In most circumstances the lateral column is fixed using 1.6- or 2-mm K-wires.320 Both screw234 and plate fixation163 have also been described. More recently, fixation techniques have been adapted to the functional anatomical aspects of a rigid medial and a flexible lateral TMT complex. If articular involvement of fractures of the cuneiforms or corresponding metatarsals exceeds 25% of the articular surface area, open reduction and stable fixation using a 2.7-mm plate is recommended. Small fragments should be excised and joints debrided; large fragments require reduction and fixation. Some cases will require adjunct use of external or internal spanning fixation.163 
In these cases, early hardware removal is recommended before the start of unprotected weight bearing to prevent hardware complications (irritation, loosening, and breakage) and to release essential joints. Current evidence regarding implant removal is insufficient to answer the questions of, if, and when best to remove the implants. 
Postoperative care follows the nonoperative treatment protocol (see above); however, we remove hardware at 12 weeks after operative treatment if causing problems or transfixing essential joints (Table 62-11). 
 
Table 62-11
ORIF of Tarso-Metatarsal Injuries
View Large
Table 62-11
ORIF of Tarso-Metatarsal Injuries
Surgical Steps
 

CRIF:

  •  
    Apply axial traction (via first toe or finger trap) to distract across TMT joint
  •  
    Reduce second MT base using pointed clamps percutaneously and provisionally stabilize with 1.25-/1.6-mm K-wires
    •  
      Restore joint congruity (do not tolerate articular steps >1 mm)
    •  
      Indirect reduction of joint component possible using 1.25-mm K-wire
    •  
      Restore column length and temporarily stabilize column using an external fixator
  •  
    Fracture fixation using at least one and, if possible, two 2.7-mm low-profile cortical screws, alternatively 3.5-mm low-profile cortical screw
    •  
      Increase stability using washer
    •  
      Increase stability by transfixing to cuboid or cuneiforms
 

ORIF:

  •  
    Assess associated compartment syndrome using invasive pressure measurements
    •  
      If present, proceed with fasciotomy
  •  
    Use two or three incisions for surgical access to displaced or unstable TMT complex
  •  
    Subperiosteal exposure of apical and distal TMT-joint complex
  •  
    L-shape arthrotomy
  •  
    Apply column distractor or external fixator across TMT joint
    •  
      Restore medial and lateral column length
     
    Simple fracture pattern
    •  
      Open split portion of fracture, debride fracture zone and joint surfaces
    •  
      Preserve plantar soft tissue attachments
    •  
      Reduce split component using pointed clamps and provisionally stabilize with K-wires
     
    Comminuted fracture pattern
    •  
      Reduce comminution component (if <25% of joint surface), augment with bone graft and provisionally stabilize with 1.25-mm K-wires
    •  
      Restore osseous anatomy (length, axial alignment, and rotation)
    •  
      Restore joint congruity using adjacent bone as template (do not tolerate articular steps >1 mm)
    •  
      Apply one-third tubular or 2.0-/2.7-mm reconstruction plate dorsal to related TMT joint
  •  
    Assess alignment using intraoperative simulated weight-bearing x-rays in 3 planes (AP, LAT, OBL)
  •  
    Assess the stability of the medial and lateral columns of the foot with intraoperative dynamic fluoroscopy
    •  
      If unstable, proceed with adjunct internal/external spanning technique
  •  
    If unreconstructable (joint involvement >25%), proceed with primary arthrodesis
X
Primary Arthrodesis.
With our modern understanding of the functional anatomy of the foot, knowing that the medial column bears the majority of weight during gait and that motion is restricted, thus, mobility of the medial column of the TMT complex is not essential for gait, restoration of arch height and length is essential and fusion has become an option.134 Hansen132 separated the function of the joints of the foot into essential, nonessential, and unnecessary. While the fourth and fifth TMT joints are classified as nonessential, their function within the lateral column of the foot is important providing a cushioning effect during midstance when bearing weight. 
Primary arthrodesis has been reported to lead to improved functional outcomes for comminuted Lisfranc fracture–dislocations with destruction of the articular surface.141,191,279 The extent of articular compromise needed to indicate a primary arthrodesis has not been determined, but destruction of more than 50% of the articular surface area has been proposed as an indication for fusion.95 Others have recommended fusion in selected cases when there is (1) major ligamentous disruption combined with multidirectional instability of the TMT joint complex, (2) a comminuted intra-articular fracture at the metatarsal base of the medial complex, or (3) a midfoot crush injury combined with intra-articular fracture–dislocation.65 Arthrodesis of the lateral column of the TMT joint complex should be avoided however.234 The increased mobility of the fourth and fifth TMT rays is important for normal foot function. Therefore, the fourth and fifth TMT joints have been characterized as “essential joints” within the TMT joint complex.141 
Operative Technique.
The patient is positioned supine on a translucent fracture table. Using a 15-degree wedge under the affected hip the leg is placed in neutral position. The surgical approach is the same as for ORIF (see above) using universal dorso-medial and dorso-lateral incisions. The degree and extent of instability requires reevaluation by visual examination and dynamic radiography. Typically, abduction–pronation and extension–flexion stresses are applied to the TMT complex with the hindfoot being held fixed with one hand. Since the medial three TMT joints are “unnecessary” and relatively immobile, either one, two or all three joints can be fused. After exposure of the TMT joint complex, an arthrotomy is performed and the joint is inspected often with the help of a medially applied distractor or external fixator. Fracture zones are debrided, small fragments resected, and larger fragments temporarily fixed. The course of reduction and temporary fixation we prefer is similar to ORIF starting with the second TMT joint and proceeding laterally. Others recommend starting TMT reduction addressing the first TMT joint first.65 Use curettes and small curved osteotomes to remove the cartilage from the respective joint surfaces to expose the subchondral bone. Then perforate the subchondral bone in several places using a 1.25-mm K-wire or a 1.6-mm drill. Using an oscillating saw is not recommended due to the risk of removing too much bone and causing shortening.65 Keep in mind that the first TMT surface is oval-shaped in the dorso-plantar direction and its diameter averages 30 mm.302 Therefore, plantar and lateral chondral debridement can be tricky, and, if left behind, dorsal and varus malalignment may result. Due to functional ball-and-socket arrangement of this joint, rotational malalignment also needs to be avoided to prevent deformity. Exact reduction of the first–second intermetatarsal joint space will facilitate optimal positioning of the first ray. Temporary fixation is performed as with ORIF, and then stability and alignment are reassessed using dynamic fluoroscopy. Screw fixation is performed using a compression lag screw technique with the screw configuration used in ORIF. Either 2.7- or 3.5-mm low-profile, cortical screws are inserted. To increase stability, a crossed fixation technique can be used.133 Before introduction of the retrograde screw in the dorsal base of the first metatarsal, a trough is created in its cortex.133,199 If plate fixation is selected a more extensive exposure is necessary. Use a 2.7-mm (mandibular) reconstruction plate, a 1/3-tubular plate, or a precontoured Lapidus arthrodesis plate. Place it medially using a proximal-to-distal fixation method. In selected cases, bone graft or allograft can be used to fill gaps and improve osseous healing (Fig. 62-27) (Table 62-12). 
Figure 62-27
A 48-year-old man sustained a crush injury of the tarsus after being run over by a truck.
 
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
View Original | Slide (.ppt)
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
View Original | Slide (.ppt)
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
View Original | Slide (.ppt)
Figure 62-27
A 48-year-old man sustained a crush injury of the tarsus after being run over by a truck.
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
View Original | Slide (.ppt)
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
View Original | Slide (.ppt)
A: Radiographic stability assessment using intraoperative dynamic fluoroscopy demonstrates TMT subluxation under stress (yellow arrows), a base of the first metatarsal fracture (solid black arrows), subcapital fractures of the second, third and fourth metatarsals (broken arrows), and a base fracture of the fifth metatarsal (white arrow). B and C: Temporary reduction was secured using pointed reduction clamps and 1.6- to 2.0-mm K-wires. Due to significant articular compromise of TMT-1, a primary arthrodesis of the first ray was chosen. (D) anterior–posterior and (E) lateral weight-bearing images at 10 weeks follow-up prior to K-wire removal. F, G and H: Radiographs at 14 months follow-up demonstrate a solid fusion of the first TMT joint and preservation of the fourth and fifth TMT joint space.
View Original | Slide (.ppt)
X
 
Table 62-12
Primary Arthrodesis of Tarso-Metatarsal Injuries
View Large
Table 62-12
Primary Arthrodesis of Tarso-Metatarsal Injuries
Surgical Steps
  •  
    See surgical steps for CRIF/ORIF
  •  
    Typically first–third TMT joint
    •  
      Use anteromedial approach and expose joints
    •  
      Start with reduction and fixation of malaligned or unstable cuneiforms to create stable cuneiform complex
    •  
      In order, reduce TMT joints TMT-2->TMT-1->TMT-3
  •  
    Apply medial column distractor across TMT-1 joint
    •  
      Place first 2.5-mm Schanz pin in medial cuneiform or talar neck/head
    •  
      Place second 2.5-mm Schanz pin in base of first MT parallel to joint surface
    •  
      Debride joint surfaces using mallets, osteotomes, curettes, and drills
  •  
    Align TMT-1 in neutral position and temporarily transfix it with 1.6-mm K-wires
    •  
      Assess alignment in AP, LAT, and OBL projections (simulated weight bearing), if necessary correct malalignment prior to definite fixation
  •  
    Perform definite fixation
    •  
      Alone or in combination with ORIF of TMT 2/3
    •  
      Screw or plate fixation optional:
      •  
        Screw fixation:
         
        Apply lag screw technique for compression
         
        Use 2.7- or 3.5-mm low-profile, cortical screws with crossed antegrade/retrograde fixation technique
         
        Use screw hole technique199 for retrograde screw placement
      •  
        Plate fixation:
         
        Use 2.7-mm plate or preformed Lapidus arthrodesis plate
         
        Proceed from proximal to distal fixation
    •  
      Increase stability by transfixing to base of TMT 2 and/or cuneiforms
  •  
    Optional, add bone graft (local, distal tibia, or calcaneus)
  •  
    Proceed with TMT 2/3 fusion as described above, if internal fixation not an option
  •  
    Assess alignment and stability of TMT 4/5
    •  
      Arthrodesis not recommended!
    •  
      Temporarily transfix to cuboid using 1.6-or 2.0-mm K-wires
  •  
    Reassess alignment via simulated weight-bearing x-rays
  •  
    Reassess stability using dynamic fluoroscopy
X
The main goal of surgical treatment is restoration of both columns of the Lisfranc complex. Preservation of the “essential joints” of the lateral TMT joint complex is paramount and pseudoarthrosis is favored over arthrodesis. Open reduction and fixation should only be performed in a safe environment of adequate soft tissues coverage. If clinical signs of a compartment syndrome are apparent, secondary reconstruction following a period of temporary spanning external fixation and soft tissue decompression is obligatory. The overarching principle is that displaced TMT injuries or nondisplaced TMT injuries with associated tarsal fractures or ligamentous instability require an aggressive treatment regime including stable open reduction and internal fixation or primary arthrodesis. 
Postoperative Care.
A bivalved below-knee cast is applied immediately after diagnosis or operative treatment to allow room for swelling of the extremity. The use of a removable walker requires a high level of patient compliance. The amount of weight bearing allowed varies substantially and depends upon the fracture pattern, injury severity, associated injuries, and patient dependent variables. Also, patient compliance will significantly influence the degree and duration of weight-bearing restrictions. Usually short-leg cast immobilization is used for 6 weeks with toe-touch weight bearing on crutches. 

Outcomes and Complications

Irrespective of injury mechanism, injury severity, or patient-specific variables, the restoration and maintenance of anatomic alignment and articular congruity are determinants of improved functional outcome. Preservation of anatomical alignment, especially of the medial column, has been linked to a good outcome. In one retrospective analysis,107 the results of 15 patients sustaining pure ligamentous Lisfranc injuries were investigated. Although not substantiated by sound statistics, flattening of the medial longitudinal arch was associated with a poor functional outcome including persistence of pain, a change in the level of activity or return to work status, and shoe modifications. Interestingly, both a delay in treatment and work-related injuries have been correlated with significantly reduced functional outcomes.56,297 In the long-run, primary arthrodesis has been shown to result in better functional outcomes when compared to open reduction and fixation at both mid-term (24 months)141 and long-term (42 months)191 follow-up. We observed that the early rehabilitation phase (first 6 months) is usually associated with reduced functional outcomes, which will improve during the first year after primary intervention. In this context Ly et al.191 showed that after both ORIF and arthrodesis of isolated ligamentous Lisfranc injuries, an improvement in the functional outcome occurred over time. The patient’s estimated level of functional participation improved from 62% to 92% after ORIF and from 44% to 65% after arthrodesis compared to their preinjury status. Henning et al.141 observed an improvement in functional outcomes on the bother and dysfunction index subscales of the SMFA after ORIF and arthrodesis over time. In addition, significantly greater functional disability has been reported with secondary operative treatment in a comparative study of early and delayed surgical treatment.279 
Complications are common and can be separated into early- and late-onset complications. In the early stages compartment syndrome,16,191,245 wound infection, and healing disturbances are common.135,245,279 Wilson357 reported vascular compromise leading to impaired circulation of the toes in three out of 20 patients. Late-onset complications include post-traumatic or secondary osteoarthritis,197,296 healing disturbances such as delayed union or nonunion,135,141,191,245,279 chronic pain,16,357 and hardware problems (local irritation, loosening, breakage)141,191,279 (Fig. 62-28). 
Figure 62-28
Seven months after rigid fixation of the medial TMT complex using 2.7-mm cortical screw fixation in a 36-year-old woman.
 
This AP view shows screw breakage at TMT-3 (white circle/arrow 1) resulting in persistent pain during full weight bearing.
This AP view shows screw breakage at TMT-3 (white circle/arrow 1) resulting in persistent pain during full weight bearing.
View Original | Slide (.ppt)
Figure 62-28
Seven months after rigid fixation of the medial TMT complex using 2.7-mm cortical screw fixation in a 36-year-old woman.
This AP view shows screw breakage at TMT-3 (white circle/arrow 1) resulting in persistent pain during full weight bearing.
This AP view shows screw breakage at TMT-3 (white circle/arrow 1) resulting in persistent pain during full weight bearing.
View Original | Slide (.ppt)
X
Also stiffness, pes planus, pes cavus, and bunion deformities, as well as gait disturbances have been reported.40,250,357 Henning et al.141 reported significantly fewer secondary operative interventions following primary arthrodesis compared to ORIF. 
Secondary osteoarthritis remains the most common sequela after both nonoperative and operative TMT injury treatment.357 Often the degree of radiographically documented osteoarthritis does not correlate well with the clinically evident degree of disability.163 Secondary arthrodesis of the affected joints remains an effective salvage procedure in the case of treatment failure.141,163,243,296 

Author’s Preferred Treatment

 
 

Stable nondisplaced TMT injuries are treated conservatively with immobilization in a cast for 6 to 8 weeks. If there is any doubt regarding instability on the weight-bearing radiographs, dynamic imaging is performed.

 

For operative treatment, the patient is positioned in the supine position on a translucent table. The leg can be placed on a triangular cushion to achieve a plantigrade foot position when using the C-arm. We prefer to use two surgical approaches (dorso-medial and dorso-lateral) in complete TMT complex injuries. First the medial TMT complex is addressed. The cuneiforms are evaluated for intercuneiform instability, and, if unstable they are reduced using a pointed reduction clamp and intercuneiform fixation is performed (2.7-mm low-profile cortical screws, lag screw technique) in a medial-to-lateral direction. Two 2.7-mm screws provide sufficient stability to obtain a stable main tarsal body. Next, the second metatarsal is reduced back to its original position between the medial and lateral cuneiforms. Exact anatomic reduction of the base of the second metatarsal is secured with temporary K-wire fixation. We prefer an open reduction technique over an insufficient closed reduction because the improved visualization allows us to debride joints of obstructing capsulo-ligamentous tissue or osseous particles. Next, the “Lisfranc screw” is introduced from the proximal medial border of the medial cuneiform into the base of the second metatarsal. Following this a 2.7-mm cortical screw is inserted in a retrograde distal-to-proximal direction transfixing MT 2 and the intermediate cuneiform (Fig. 62-28).

 

The first TMT joint should be stabilized after other parts of the joint complex have been fixed. It is anatomically reduced using a reduction clamp or pointed forceps and temporary fixation is provided by 1.6- or 2-mm K-wires. Rotational deformity needs to be ruled out using standardized intraoperative simulated weight-bearing radiographic imaging to confirm restoration of both alignment and articular congruence. To obtain ideal fixation in some cases we inspect the first intermetatarsal space before fixing the first ray to the base of MT 2. Temporary fixation using 2-mm K-wires is followed by definite 2.7-mm cortical screw fixation. For all screws which start in the metatarsals, countersinking is mandatory to prevent cortical avulsion during screw compression. Usually we insert two crossing cortical screws using a lag screw technique starting with the distal-to-proximal screw and followed by proximal-to-distal screw placement. The TMT-3 joint is addressed next. After exact reduction, a distal-to-proximal 2.7-mm screw provides sufficient stability for TMT-3 fixation. As an alternative, a 5-hole 2.7-mm reconstruction plate can be placed on the dorsal surface of the joint complex to provide a more stable fixation construct. If the lateral TMT joint complex does not automatically reduce after restoration and rigid fixation of the medial TMT column complex, a closed reduction attempt can be performed. The fourth and fifth metatarsals usually perform as a single functional unit, and thus, reduction of one automatically reduces the second. However, in some circumstances capsulo-ligamentous tissue or bone fragments interfere with anatomic realignment, and hence, an open approach is required. TMT 4/5 can easily be accessed via a dorso-lateral approach. Usually fixation is carried out with converging K-wires. We prefer 2.0- over 1.6-mm K-wires to increase stability. If the fourth/fifth intermetatarsal interface is unstable a transverse intermetatarsal blocking screw can be introduced distal to the bases of the two metatarsals in a lateral-to-medial direction. Typically, a 3.5-mm mini-fragment cortical screw is used, but a 2.7-mm screw is an option.

 

In the case of comminution, we recommend bridge plating with a 2.7-mm reconstruction plate. The plate can be placed on the tarsal navicular or the talar head if talo-navicular instability has been identified. It should be remembered that the medial column bridging plate is meant to be a temporary immobilization device and not placed to create a permanent arthrodesis. The technical details of this method have been described in detail.308 With regard to comminution of the lateral TMT column complex, development of a pseudoarthrosis is preferred over arthrodesis. Complete TMT complex fusion is considered to be a salvage procedure. In these cases a staged fusion is sought, first of the medial TMT complex, and then second of the lateral TMT complex in case of persistent disability.

 

If comminution and instability of the medial TMT joint complex precludes anatomic reconstruction, we perform internal bridge plating which can be performed at each TMT joint of the medial complex. Internal spanning fixation of the lateral TMT complex is possible but necessitates removal of the bridging plate before the start of weight bearing. If medial column bridging has been performed the essential talo-navicular joint has to be freed up by plate shortening or removal in order to allow weight bearing to progress. Other implants within the rigid parts of the tarsal complex can remain in place if free of complications (Figs. 62-29 and 62-30).

 
Figure 62-29
 
Displaced TMT fracture–dislocation of the right foot in a 24-year-old woman with diabetes after a low-energy supination-abduction injury with an associated displaced cuboid fracture. A: The initial AP view. B: Lateral view. C: CT axial reconstruction view. D: Intraoperative radiograph after open reduction and internal fixation of the medial TMT complex and temporary 1.6-mm K-Wire fixation of the lateral complex. E: Intraoperative fluoroscopic view after ORIF of the cuboid fracture. F and G: Final postoperative radiographs.
Displaced TMT fracture–dislocation of the right foot in a 24-year-old woman with diabetes after a low-energy supination-abduction injury with an associated displaced cuboid fracture. A: The initial AP view. B: Lateral view. C: CT axial reconstruction view. D: Intraoperative radiograph after open reduction and internal fixation of the medial TMT complex and temporary 1.6-mm K-Wire fixation of the lateral complex. E: Intraoperative fluoroscopic view after ORIF of the cuboid fracture. F and G: Final postoperative radiographs.
View Original | Slide (.ppt)
Displaced TMT fracture–dislocation of the right foot in a 24-year-old woman with diabetes after a low-energy supination-abduction injury with an associated displaced cuboid fracture. A: The initial AP view. B: Lateral view. C: CT axial reconstruction view. D: Intraoperative radiograph after open reduction and internal fixation of the medial TMT complex and temporary 1.6-mm K-Wire fixation of the lateral complex. E: Intraoperative fluoroscopic view after ORIF of the cuboid fracture. F and G: Final postoperative radiographs.
View Original | Slide (.ppt)
Figure 62-29
Displaced TMT fracture–dislocation of the right foot in a 24-year-old woman with diabetes after a low-energy supination-abduction injury with an associated displaced cuboid fracture. A: The initial AP view. B: Lateral view. C: CT axial reconstruction view. D: Intraoperative radiograph after open reduction and internal fixation of the medial TMT complex and temporary 1.6-mm K-Wire fixation of the lateral complex. E: Intraoperative fluoroscopic view after ORIF of the cuboid fracture. F and G: Final postoperative radiographs.
Displaced TMT fracture–dislocation of the right foot in a 24-year-old woman with diabetes after a low-energy supination-abduction injury with an associated displaced cuboid fracture. A: The initial AP view. B: Lateral view. C: CT axial reconstruction view. D: Intraoperative radiograph after open reduction and internal fixation of the medial TMT complex and temporary 1.6-mm K-Wire fixation of the lateral complex. E: Intraoperative fluoroscopic view after ORIF of the cuboid fracture. F and G: Final postoperative radiographs.
View Original | Slide (.ppt)
Displaced TMT fracture–dislocation of the right foot in a 24-year-old woman with diabetes after a low-energy supination-abduction injury with an associated displaced cuboid fracture. A: The initial AP view. B: Lateral view. C: CT axial reconstruction view. D: Intraoperative radiograph after open reduction and internal fixation of the medial TMT complex and temporary 1.6-mm K-Wire fixation of the lateral complex. E: Intraoperative fluoroscopic view after ORIF of the cuboid fracture. F and G: Final postoperative radiographs.
View Original | Slide (.ppt)
X
 
Figure 62-30
Algorithm for the treatment of TMT joint injuries.
 
TMTI, tarso-metatarsal injury; AFI, associated foot injury; LDF, Lisfranc dislocation fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
TMTI, tarso-metatarsal injury; AFI, associated foot injury; LDF, Lisfranc dislocation fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
View Original | Slide (.ppt)
Figure 62-30
Algorithm for the treatment of TMT joint injuries.
TMTI, tarso-metatarsal injury; AFI, associated foot injury; LDF, Lisfranc dislocation fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
TMTI, tarso-metatarsal injury; AFI, associated foot injury; LDF, Lisfranc dislocation fracture; CRIF, closed reduction and internal fixation; ORIF, open reduction and internal fixation; PA, primary arthrodesis.
View Original | Slide (.ppt)
X

Injuries of the Forefoot

Introduction to Forefoot Injuries

Fractures of the forefoot are common and may result in significant sequelae. The forefoot as a unit provides a broad plantar surface for load sharing. This platform also is structured to be mobile in the sagittal plane and provides the forefoot with the ability to alter the position of the individual metatarsal heads to accommodate uneven ground. Therefore, injuries to this area can lead to difficulties with ambulation and gait. Although the forefoot appears to work as a single unit, its parts are distinctly different and need to be treated accordingly in the case of injury. 

Metatarsal Fractures

The metatarsals are a common fracture site in the body and account for 35% of all foot fractures.317 Metatarsal fractures occur most often in patients between 20 and 50 years of age.263 These fractures occur as isolated injuries, concurrently with fractures of additional metatarsals, or in complex foot trauma. The mechanisms of injury resulting in metatarsal fractures include direct and indirect trauma forces, with direct injuries being the most common cause.195 Although most metatarsal fractures are a result of low-energy trauma,263 high-energy crush injuries do occur with some frequency, and they are the most common injuries sustained in motorcycle accidents.256 A direct force can result in the fracture of any metatarsal at any point and may be accompanied by severe soft tissue envelope injury and compartment syndrome. The most common metatarsal fractures are those of the fifth metatarsal.263 
Metatarsal fractures can occur at any location on the bone and are generally divided by the region of occurrence into proximal metaphyseal, diaphyseal or shaft, and head and neck fractures.50 Proximal metaphyseal and metatarsal base fractures often stay relatively well aligned because of the numerous articulations and soft tissue attachments,213,261,263 but they may be associated with a Lisfranc joint dislocation. Diaphyseal fractures may have several patterns but are often oblique and tend to shortening, angulation, and displacement.214 Distal metaphyseal fractures are commonly transverse or oblique. Displacement typically occurs plantarly and laterally. Avulsion fractures, particularly of the base of the fifth metatarsal, are common. Stress fractures also occur commonly in the metatarsals, particularly at the second and third metatarsal necks and at the proximal portion of the shaft of the fifth. Despite their frequency, most metatarsal fractures do not cause significant problems in treatment or outcome, but they can lead to significant limitations if ignored.214 
Because of the unique function of the first and fifth rays and the commonality between the central metatarsals, it is useful to examine metatarsal fractures in these separate components: first metatarsal, central metatarsals (including second, third, and fourth), and fifth metatarsal.50 

First Metatarsal Fractures

Pathoanatomy and Applied Anatomy Relating to First Metatarsal Fractures

The first metatarsal is stronger than the other metatarsals. It accounts for approximately 1.5% of all metatarsal fractures.263 Its large cross-sectional geometric properties reflect its role as the preferred ray for loading during walking, running or turning in a different direction.122 Its configuration is shorter and wider than the lesser four metatarsals. The lack of interconnecting ligaments between the first and second metatarsals allows independent motion. The bony architecture in combination with strong thick ligaments that make up the capsule of the first TMT joint, support its resting position. There are two powerful motor attachments to its base. The tibialis anterior inserts on the plantar medial aspect of the first metatarsal base and the peroneus longus attaches onto the plantar lateral base of the first metatarsal. These two muscles exert significant influence on the position of the first metatarsal head. The tibialis anterior serves to elevate the first metatarsal and the peroneus longus acts to plantarflex the head. Average peak pressures in MT 1 are the highest or among the highest levels of pressure during most activities.122 
First Metatarsal Injury Mechanisms.
First metatarsal fractures can result from direct or indirect forces. Direct injuries are more common in industrial settings and occur often as a result of a heavy object falling on the foot. Indirect injuries result from situations often seen in sports, when the forefoot is fixed and the leg or foot is twisted.314 
Injuries to the first metatarsal may be related to fractures of the central metatarsals, injuries to other parts of the first ray, and Lisfranc injuries. Any fracture of the base of the first three metatarsals should raise suspicion of a midtarsal injury. Small avulsion fractures involving the medial base of the first or second metatarsal suggest disruption of the TMT ligaments. The arterial arch and the dorsal and plantar metatarsal arteries are particularly susceptible to injuries in association with metatarsal fractures. Compartment syndrome is relatively common with soft tissue trauma in the metatarsal area, and compartment pressures should be monitored routinely, especially following direct trauma. 

Signs and Symptoms of First Metatarsal Fractures

Patients normally describe pain with weight bearing and active motion of the foot and therefore have difficulties with ambulation. Physical examination reveals tenderness and swelling. Crepitation and palpable motion may be present at the fracture site and reproduce the patient’s symptoms. This may be used as a diagnostic tool for stress fractures. The neurovascular status should be evaluated, because the arterial arch and the dorsal and plantar metatarsal arteries are particularly susceptible to injuries in association with metatarsal fractures. 

First Metatarsal Fracture Imaging

Radiographic evaluation is critical to assess metatarsal fractures for consideration of treatment options. Three views (AP, lateral, and oblique) are mandatory to judge shortening, deviation, angulation, and displacement.214 Additional information regarding intra-articular fracture lines and fragments can be obtained through computed tomography. MRI can provide additional information related to soft tissue injuries. 

First Metatarsal Fracture Classification

The OTA classification for metatarsal fractures permits a detailed description of the fracture pattern of each bone but does not offer any insight into overall stability or treatment.207 The designation of metatarsal fractures under this system observes the format: (87()-_ _._) in a fashion similar to the metacarpals of the hand. To denote the first metatarsal (T) an identifier should be placed in parentheses beside the major designation. Extra-articular simple fractures are designated A. The letter B denotes partial articular involvement or wedge fracture of the shaft. And C denotes complete articular involvement and or comminuted shaft fractures. Further subclassification is given to accurately place the fracture: Proximal, central, or distal. Each of these groups is further divided by the final description of the fracture. 
No special outcome score or scale exists for the first metatarsal. The AOFAS midfoot score is most commonly utilized to distinguish clinical outcome. In addition the SMFA and SF-36 are helpful tools to assess overall clinical outcome. 

First Metatarsal Fracture Treatment Options

Nonoperative Treatment.
The best way to determine operative or nonoperative treatment is with stress radiographs. Manual displacement of the position of the first metatarsal through the joint or fracture site represents an instability that requires fixation. If no evidence of instability can be seen on stress films of the fracture, and no other injuries of the midfoot or metatarsals are evident, isolated minimally displaced first metatarsal fractures can be adequately treated. 
Isolated first metatarsal fractures can be adequately treated in a short-leg cast with no weight bearing for 3 weeks and then for an additional 3 weeks with weight bearing as tolerated (Table 62-13).213 Casting should be performed with the foot in a plantigrade position yet without placing dorsally directed pressure on the first metatarsal. The best way to apply the cast is with the patient in the prone position with knee of the affected limb flexed to 90 degrees and placing gentle pressure on the lesser metatarsals to obtain a plantigrade position. Activities are then advanced as tolerated in a walking cast until there is comfortable full weight bearing before advancing to regular shoes or increased activity. 
 
Table 62-13
First Metatarsal Fractures
View Large
Table 62-13
First Metatarsal Fractures
Nonoperative Treatment
Indications Relative Contraindications
Isolated fracture Complex fractures of the forefoot/midfoot
No instability on stress radiographs Instability on stress radiographs
Minimal displacement Plantar displacement of the metatarsal head
Open fractures
X
Operative Treatment of First Metatarsal Fractures.
Any evidence of instability or loss of normal position of the metatarsal head should be treated with operative stabilization. The goal is to restore and maintain the normal position of the first metatarsal head, the sesamoids, and the first metatarso-phalangeal joint. The method of fracture fixation is dependent on fracture configuration. 
Operative contraindications may include patient factors, vascular compromise, local infection, or medical instability. 
Simple and easily reducible fractures of the shaft or either articular surface can be fixed with percutaneous smooth wires. Displaced fractures should be treated by open reduction and internal fixation. Simple oblique or spiral fractures, whether diaphyseal or intra-articular, are best treated with lag screw fixation with 2.7-mm screws after open reduction. With stabilization of the fracture, reassessment of the stability of the TMT joint should be performed. If the joint is thought to be unstable, a 2.7- or a 3.5-mm fixation screw can be placed across the joint similar to the manner used to stabilize the first TMT joint in a Lisfranc injury if the fracture pattern permits. More commonly because of the fracture pattern, this joint instability is treated with a contoured one-third tubular plate and 3.5-mm screws. The plate must extend from the medial cuneiform to the distal intact aspect of the shaft to obtain proper purchase. 
The one-third tubular plate can also be used to treat more comminuted fractures when lag screw fixation is not possible. The determining factor is whether there is enough intact bone distally to obtain secure fixation of the plate. Fracture patterns involving severe comminution of the proximal half of the metatarsal are amenable to this type of fixation. Plate and screw fixation should be used for transverse or minimally comminuted fractures in which inadequate fixation will occur with screws or wires alone. More comminuted fractures of the base with intact soft tissues can also be treated by plate fixation extending from the medial cuneiform to the first metatarsal shaft to restore length and axial alignment (Fig. 62-31). 
Figure 62-31
Comminuted fracture of the first metatarsal.
 
(A) AP and (B) oblique view radiographs at injury. C and D: Open reduction and internal fixation was performed using a mini-fragment plate.
(A) AP and (B) oblique view radiographs at injury. C and D: Open reduction and internal fixation was performed using a mini-fragment plate.
View Original | Slide (.ppt)
Figure 62-31
Comminuted fracture of the first metatarsal.
(A) AP and (B) oblique view radiographs at injury. C and D: Open reduction and internal fixation was performed using a mini-fragment plate.
(A) AP and (B) oblique view radiographs at injury. C and D: Open reduction and internal fixation was performed using a mini-fragment plate.
View Original | Slide (.ppt)
X
External fixation should be considered when there is severe midshaft or head comminution or open injuries. These fracture patterns usually have significant soft tissue damage associated with them, and they should be stabilized without creating further soft tissue trauma. The fixator is used to restore first metatarsal axial length and alignment with the forefoot without further compromise to the soft tissue. 
First metatarsal fractures exhibiting severe comminution with inadequate intact bone to support a plate are best handled by external fixation. Fixator pins can find purchase in the intact midfoot and proximal phalanx to establish length and position. Secondary pins can be used to secure intact segments of the metatarsal to further control alignment. If the proximal phalanx is used to stabilize the fracture, care should be taken in the final positioning. The external fixator should be placed such that the proximal phalanx is at minimum in a plantigrade position but it should be slightly dorsiflexed if possible. This is to prevent problems of toe position in the event of joint stiffness post injury (Fig. 62-32). 
Figure 62-32
The use of an external fixator for a severe first metatarsal fracture.
 
A, B: Injury films showing significant disruption of the metatarsal shaft. C, D: Placement of an external fixator with restoration of metatarsal length and alignment.
A, B: Injury films showing significant disruption of the metatarsal shaft. C, D: Placement of an external fixator with restoration of metatarsal length and alignment.
View Original | Slide (.ppt)
Figure 62-32
The use of an external fixator for a severe first metatarsal fracture.
A, B: Injury films showing significant disruption of the metatarsal shaft. C, D: Placement of an external fixator with restoration of metatarsal length and alignment.
A, B: Injury films showing significant disruption of the metatarsal shaft. C, D: Placement of an external fixator with restoration of metatarsal length and alignment.
View Original | Slide (.ppt)
X
Surgical Technique.
The patient is positioned supine on a radiolucent table. A mini-fluoroscopy unit can be positioned at the end of the operating table, or standard fluoroscopy located opposite the injured extremity. 
The surgical approach for fracture of the first metatarsal to some degree depends on the configuration of the fracture. For simple avulsions at the metatarsal base, an incision directly over the fracture may be best for direct visualization of reduction. For the majority of proximal and midshaft fractures, a dorsal-lateral approach through the first intermetatarsal space is adequate for visualization of reduction and fixation. This incision can be extended distally and proximally to allow access for a bridging plate if needed. The approach should be done carefully to avoid unnecessary disruption of tissue planes. In this area of the forefoot lie the dorsalis pedis artery and the deep peroneal nerve. Branches of the superficial peroneal nerve can be found overlying the deeper structures. These structures need to be identified and protected during the surgical dissection and closure (Table 62-14). 
 
Table 62-14
ORIF of First Metatarsal Fractures
View Large
Table 62-14
ORIF of First Metatarsal Fractures
Surgical Steps
Dorsal–lateral approach through the first–second intermetatarsal space
Careful preparation to avoid damage to the dorsalis pedis artery and the deep peroneal nerve
Subperiosteal exposure of fracture site
Cleaning of fracture ends with a curette
Reduction and temporary fixation with bone-holding forceps
Lag screw or one-third tubular plate fixation depending on the fracture pattern
Layered closure
X
Postoperative Care.
Postoperatively, immobilization should allow for management of the soft tissues. If the soft tissues are reasonable, a short-leg cast is appropriate. If wound care is needed, immobilization should be conducted with a removable splint. The patient should be kept non-weight-bearing for 6 to 8 weeks and then transferred into a postoperative boot.213 During follow-up, radiographic analysis is performed at fixed intervals at 2, 6, 12 weeks, and up to 1 year to identify fracture healing but is also required to identify the development or presence of complications. 
Potential Pitfalls and Preventative Measures.
The base of the first metatarsal should not be overlooked when evaluating a patient who has an inversion type injury. Avulsion fractures may occur at the first metatarsal base with plantar flexion and inversion type injuries because of the attachments of the peroneus longus and tibialis anterior tendon at this level.50,213 In addition, small avulsion fractures involving the medial base of the first or second metatarsal suggest disruption of the metatarsal ligaments. Any displacement or diastasis of more than 2 mm between the base of the first and second metatarsals on an anteroposterior radiograph of the foot should raise suspicion of a Lisfranc ligament injury and be evaluated using stress radiographs.213 In addition, changes to the metatarsal length or sagittal alignment affects weight-bearing biomechanics of the first ray. Plantigrade dislocation of the first metatarsal head can result in plantar pressure lesions.213 

Adverse Outcomes and Unexpected Complications

The axes of the forefoot are in balance when half of the weight passes through the first and second metatarsals and the other half of the weight passes through the third, fourth, and fifth metatarsals.233 During most activities, the highest levels of pressure are found under the first metatarsal.122 Therefore, nonunion or malunion of the first metatarsal can result in significant morbidity due to its essential role as the preferred ray for loading during walking, running, or turning in a different direction.122 Disruption of the functional integrity of the first metatarsal can disturb the normal gait and cause pain at the first metatarso-phalangeal joint, proximally along the medial column, which can lead to gait disturbances that can affect the entire limb.50 

Author’s Preferred Treatment

 
 

An algorithm outlining the authors’ preferred treatment of first metatarsal fractures can be found in Figure 62-33.

 
Figure 62-33
An algorithm for the treatment of first metatarsal fractures.
Rockwood-ch062-image033.png
View Original | Slide (.ppt)
X

Central Metatarsal Fractures

Fractures of the central metatarsals account for approximately 10% of all metatarsal fractures and are often contiguous fractures. Especially fractures of the third metatarsal are related to fractures of the second or fourth metatarsal approximately 63% of the time.263 Fractures of the central metatarsals are much more common than first metatarsal fractures, although the fourth metatarsal is the least commonly injured due to protected position and flexibility of the lateral rays. These fractures can be isolated or be part of a more significant injury pattern.15 
Central metatarsal fractures can result from direct or indirect forces. Direct injuries are more common in industrial settings and occur often as a result of a heavy object falling on the foot. Indirect injuries result from situations often seen in sport, when the forefoot is fixed and the leg or foot is twisted.314 Central metatarsal fractures also often occur as stress fractures. 
Fractures of the central metatarsals are commonly associated with injuries to the first ray, and Lisfranc joint injuries. Any fracture of the base of one of the first three metatarsals should raise suspicion of a midtarsal injury. Small avulsion fractures involving the medial base of the first or second metatarsal suggest disruption of the metatarsal ligaments. Any displacement or diastasis of more than 2 mm between the base of the first and second metatarsals on an AP radiograph of the foot should raise suspicion of a Lisfranc ligament injury. The arterial arch, the dorsalis pedis artery, and the dorsal and plantar metatarsal arteries are particularly susceptible to injury in association with metatarsal fractures. 
Patients normally describe pain with weight bearing and active motion of the foot and therefore have difficulties with ambulation. Physical examination reveals tenderness and swelling. Crepitation and palpable motion may be present at the fracture site and reproduce the patient’s symptoms. This may be used as a diagnostic tool for stress fractures 
Radiographic evaluation is critical in the assessment of metatarsal fractures. Three weight-bearing views (AP, lateral, and oblique) are mandatory to judge shortening, deviation, angulation, and displacement.214 Weight-bearing films usually reveal subtle instabilities not seen on non-weight-bearing films. Additional information regarding intra-articular fracture lines and fragments can be obtained through computed tomography. A CT scan is helpful when there are fractures involving the base of the metatarsals to identify intra-articular extension and any comminution. MRI can provide additional information related to soft tissue injuries and demonstrate the degree of ligament disruption, but it is not usually required in the diagnosis of midfoot fracture–dislocations nor does it usually alter treatment. Monitoring of compartment pressures should be performed routinely especially following direct trauma. 
The OTA classification for metatarsal fractures gives a detailed description of the fracture pattern of each bone.207 Central metatarsal fractures under this system observe the format: (87()-_ _._) in a fashion similar to the metacarpals of the hand. To denote which metatarsal the classification refers to, an alpha identifier similar to the first metatarsal should be placed beside the major designation: Second metatarsal (I), third metatarsal (L), and fourth metatarsal (R). The classification system then continues similar to the first metatarsal. 
No special outcome score for the central metatarsals exists. The AOFAS midfoot score is most commonly utilized to measure clinical outcome. In addition the SMFA and SF-36 are helpful tools for overall clinical outcome. 

Pathoanatomy and Applied Anatomy Relating to Central Metatarsal Fractures

The second and the third metatarsals are important because they comprise the keystone of the foot.4 The metatarsal bases are of trapezoidal shape and form a “Roman arch” configuration. At the base of each central metatarsal is a series of three ligaments (dorsal, central, and plantar), which act to stabilize and support each with their neighbor. The only extrinsic muscular attachments seem to be slips from the tibialis posterior tendon, which insert on the plantar base.339 Their role is for structural support. These bones do provide for the origin of dorsal and plantar interossei muscles. The plantar muscles insert into the medial aspect of the associated proximal phalanx. The tendon of the dorsal muscle, however, inserts into the plantar aspect of the proximal phalanx of its medial neighbor. Finally, there is the thick transverse metatarsal ligament distally that connects the metatarsals indirectly by linking the plantar plates of the adjacent metatarso-phalangeal joints. The strong flexor tendons usually force the distal fragment of the metatarsal fracture in a plantar and proximal position.15 There is also a cascade of allowable increase in motion through the TMT joints beginning at the second metatarsal and going out to the fifth. It is this increase in motion in the sagittal plane that allows for significant adaptability to terrain by the metatarsal heads. It is also the relative resistance to motion at the second and third TMT joints that causes stress fractures to be seen more commonly in these two metatarsals. Stress fractures in the second and third MTs have also been linked to mechanical pathologies such as excessive pronation of the foot, metatarsus primus elevatus, hallux abducto valgus, and first ray hypermobility187 as well as plantar fascia rupture.1 

Central Metatarsal Fracture Treatment Options

Nonoperative Treatment.
The major rule of fracture treatment is to return the fractured part to full function. In the case of the central metatarsals emphasis should be on realignment of the metatarsal head. Although there is little in the literature documenting specific criteria for unacceptable position, the problems of transfer metatarsalgia and plantar hyperkeratosis are well-known following fractures that allow significant changes in the normal position of the metatarsal head. The criterion most often mentioned is that any fracture displaying more than 10 degrees of deviation in the sagittal plane or 3 to 4 mm of translation in any plane should be actively corrected. 
The vast majority of isolated individual central metatarsal fractures can be treated nonoperatively. That is not to mean they should be ignored. Isolated midshaft fractures, whether comminuted or simple, are usually quite stable with little shortening and can be managed adequately with hard sole or stiff shoes and progressive weight bearing as tolerated. 
Individual head or neck fractures that appreciably deviate either dorsally or plantarly in the sagittal plane are treated with closed reduction using finger trap distraction to restore alignment. A stable base fracture of the third or fourth metatarsal can be reduced closed without fixation. A base fracture of the second should be stressed to see if it has any tendency to displace laterally. Because there are no stabilizing ligaments between the first and second metatarsals, limited open reduction and intramedullary pinning of the second metatarsal can be done to maintain proper position if it has a tendency to shift laterally. 
Severely hyperextended distal metatarsal fractures may result in dislocation with the head driven through the flexor plate. This can prevent closed reduction (Table 62-15). 
 
Table 62-15
Central Metatarsal Fractures
View Large
Table 62-15
Central Metatarsal Fractures
Nonoperative Treatment
Indications Relative Contraindications
Individual head or neck fractures Unstable base fracture of the second metatarsal
Multiple adjacent metatarsal fractures
Comminution
Significant displacement
Hyperextended neck fractures
X
Prereduction radiographs should be obtained to study the extent of the fracture. Local or general anesthesia depending on the severity of the injury is required. Closed reduction for metatarsal base fractures with lateral displacement can be achieved by simultaneously plantarflexing and forcing the TMT joint medially under traction and counter-traction.214 For isolated distal central metatarsal fractures, closed reduction is performed by using finger trap distraction to restore alignment followed by weight bearing as tolerated in a hard-sole shoe. Progression to full activities is dependent solely on the reduction of symptoms. 
Operative Treatment of Central Metatarsal Fractures.
Pin fixation after closed reduction is rarely needed with an isolated injury because of the stability provided by the surrounding soft tissues. However, any appreciable deviation in metatarsal head position should be addressed with reduction and possibly pinning to maintain normal forefoot alignment. If a satisfactory closed reduction cannot be obtained, open reduction utilizing low-profile screws and plates is recommended.4 An unstable base fracture of the second metatarsal requires limited open reduction and intramedullary pinning to maintain proper position if it has a tendency to shift laterally due to the absence of stabilizing ligaments between the first and second metatarsals. 
The problem arises when there are multiple adjacent metatarsal fractures or there is significant comminution. The inherent stability provided by adjacent structures now tends to accentuate any deformity. Closed reduction can be attempted but it is usually unstable. Therefore, open reduction and internal fixation of the fracture should be performed. In this case, the choice of fixation is dependent more on the condition of the surrounding soft tissue than on the fracture pattern or location. Great care must be taken during the reduction to avoid dorsiflexion or plantar flexion of the distal fragment causing a sagittal malalignment of the metatarsal head with its neighbors. 
In the rare event of a segmental fracture of these metatarsals, a combination of procedures should be done. The proximal fracture should be exposed and control of the segmental fragment achieved with an intramedullary K-wire. Then a closed reduction of the distal fracture should be done. The metatarso-phalangeal joint is then aligned, and the pin is passed across the distal fracture and the metatarso-phalangeal joint. Finally, the proximal fracture is reduced and the wire is advanced across it in a retrograde fashion. 
Operative contraindications may include patient factors, vascular compromise, local infection, or medical instability. 
If there is significant soft tissue injury or open wound, intramedullary K-wire fixation should be performed. Use of K-wire fixation is also effective if there is severe comminution of the shaft. One must be careful not to shorten the position of the head in relation to its neighbors. 
Multiple metatarsal head or neck fractures are extremely hard to control. Many times apparently simple neck fractures from acute trauma actually extend into the head and metatarso-phalangeal joint. These fractures are difficult to treat by open means, running the risk of devascularization of the head and losing any remaining stability with disruption of the soft tissue attachments. Closed reduction with traction and local anesthesia is the preferred method of treatment. The goal is to bring what is usually a plantarflexed head back to a neutral position and impale the head on the neck of the metatarsal. Realignment can be supplemented by percutaneous pin fixation. The pin should incorporate both the metatarsal shaft and the base of the proximal phalanx to ensure stable fixation. If a pin is used to maintain the reduction, we recommend entering the base of the proximal phalanx or metatarsal head from the lateral aspect and aim to bend the pin down the medial wall of the shaft. This elastic bend in the K-wire will exert a medially directed force to balance the natural tendency for these fractures to drift laterally (Figs. 62-34 and 62-35). 
Figure 62-34
Oblique view after closed reduction internal fixation of subcapital MT 2 to 4 fractures using 1.6-mm K-wires.
Rockwood-ch062-image034.png
View Original | Slide (.ppt)
X
Figure 62-35
Central metatarsal fracture stabilization.
 
A: Typical fracture pattern. B: The fracture site is surgically exposed and a smooth wire placed distally down the shaft. C: The proximal phalanx of the toe is held in a reduced position so the pin engages the plantar cortex of the phalanx. D: The fracture is then reduced and the wire is fed through the proximal portion of the metatarsal.
A: Typical fracture pattern. B: The fracture site is surgically exposed and a smooth wire placed distally down the shaft. C: The proximal phalanx of the toe is held in a reduced position so the pin engages the plantar cortex of the phalanx. D: The fracture is then reduced and the wire is fed through the proximal portion of the metatarsal.
View Original | Slide (.ppt)
Figure 62-35
Central metatarsal fracture stabilization.
A: Typical fracture pattern. B: The fracture site is surgically exposed and a smooth wire placed distally down the shaft. C: The proximal phalanx of the toe is held in a reduced position so the pin engages the plantar cortex of the phalanx. D: The fracture is then reduced and the wire is fed through the proximal portion of the metatarsal.
A: Typical fracture pattern. B: The fracture site is surgically exposed and a smooth wire placed distally down the shaft. C: The proximal phalanx of the toe is held in a reduced position so the pin engages the plantar cortex of the phalanx. D: The fracture is then reduced and the wire is fed through the proximal portion of the metatarsal.
View Original | Slide (.ppt)
X
Interfragmentary compression is best suited for oblique fractures and is achieved with a lag screw especially in diaphyseal fractures. Transverse fractures can be treated by plates and tension band cerclage. Whereas, open reduction and plate fixation is best suited for comminuted oblique shaft fractures. 
The patient is positioned supine on a radiolucent table. A mini-fluoroscopy unit can be positioned at the end of the operating table, or standard fluoroscopy located opposite the surgical extremity. A dorsal longitudinal incision is centered over the involved bone, and the fracture site is exposed subperiosteally.314 
After the fracture ends are cleaned with a curette, the bone is reduced and temporarily held with a bone-holding forceps. The choice of fixation method depends on the fracture site and configuration.314 Reduction and implant positioning should be checked regularly by fluoroscopy. After completing the procedure, a layered closure is performed (Table 62-16). 
 
Table 62-16
ORIF of Central Metatarsal Fractures
View Large
Table 62-16
ORIF of Central Metatarsal Fractures
Surgical Steps
  •  
    Dorsal longitudinal incision centered over the involved bone
  •  
    Subperiosteal exposure of fracture site
  •  
    Cleaning of fracture ends with a curette
  •  
    Reduction and temporary fixation with bone-holding forceps
  •  
    Internal fixation
  •  
    Layered closure
X
Postoperative Care.
Postoperative care involves placing the patient in a short-leg cast for 2 weeks with the foot in a plantigrade position to allow soft tissue healing. The patient is permitted to bear weight through the heel during this time. With removal of the sutures a removable boot can be used to maintain normal foot position until the patient is comfortable to bear weight, usually by 4 to 6 weeks. The pins are removed at 4 weeks unless they are bridging a bony gap. In that case, the pin remains until radiographic evidence of bony consolidation is seen or the patient is weight bearing without pain. During this time radiographic analysis should be performed to identify fracture healing at fixed time intervals to identify the development or presence of complications. 
Potential Pitfalls and Preventative Measures.
Malalignment occurs usually because of incomplete restoration of the plantar anatomy and the metatarsal arch with abnormal weight distribution on the metatarsal heads.12 Increased plantar flexion of the metatarsal head may result in an intractable plantar keratosis due to increased loads.15 In those patients who are symptomatic upon healing of the fracture and the soft tissues, a simple osteotomy can usually correct the symptomatic deformity. Other causes of a poor outcome are more related to compartment syndrome and the energy of the initial trauma. Fracture comminution, soft tissue injury, and open injuries have been noted to lead to late symptoms of pain and stiffness regardless of the type of intervention. Causalgia and reflex sympathetic dystrophy can be caused by direct or indirect injuries to the superficial peroneal nerve, which is located superficially dorsally.4 Fixation of fractures with intramedullary wiring can lead to necrosis of the plantar surface pad.4 
An isolated proximal second, third, or fourth metatarsal fracture requires further investigation to ensure that there is no instability along the Lisfranc joint. Weight-bearing stress radiographs are recommended to confirm TMT stability. If instability is present, the fracture should be treated in the context of the Lisfranc instability. 

Management of Expected Adverse Outcomes and Unexpected Complications

Complications from treating central metatarsal fractures are generally the same as for fracture healing elsewhere. Nonoperative treatment in a cast may lead to deep vein thrombosis and strict deep vein thrombosis prophylaxis needs to be administered. Persistent and prolonged pain is the leading sign of compartment syndrome. Compartment syndrome may lead to contractures and clawtoe deformity. Mainly the interosseous compartment is involved in forefoot injuries and includes the metatarsals and needs to be examined and/or released. Nonunion of a metaphyseal fracture is relatively uncommon due to the rich blood supply in that area.339 Still, some fractures of lesser metatarsals tend to unite slowly. Additional bone grafting can promote bony union. Excessive length of a central metatarsal can lead to higher incidence of stress fractures. Therefore, correct reduction and length should be obtained. 

Author’s Preferred Treatment

 
 

An algorithm outlining the authors’ preferred treatment of central metatarsal fractures is presented in Figure 62-36.

 
Figure 62-36
Treatment algorithm for central metatarsal fractures.
Rockwood-ch062-image036.png
View Original | Slide (.ppt)
X

Fifth Metatarsal Fractures

Pathoanatomy and Applied Anatomy Relating to Fifth Metatarsal Fractures

The base of the fifth metatarsal is a complex anatomic site with the insertion of three muscles. The peroneus brevis attaches on the dorsal aspect of the tubercle of the fifth metatarsal and the peroneus tertius attaches on the dorsal aspect at the proximal metaphyseal-diaphyseal junction. Functionally, the peroneus tertius acts as a balancing force during forefoot dorsiflexion counteracting the natural inversion tendency of the tibialis anterior. The peroneus brevis serves as more of an antagonist to posterior tibialis function to maintain the position of the foot under the talus. The third muscle is the abductor digiti quinti. There is also a strong attachment of the plantar fascia to the plantar aspect of the tubercle. 
In the adolescent population, there is an apophysis at the tuberosity that can be confused for a fracture Also in this area are two sesamoid bones, which should not be mistaken for a displaced fracture. The os peroneum is located within the tendon of the peroneus longus and can be found on the lateral border of the cuboid. The os vesalianum is found just proximal to the base of the fifth metatarsal medial to the insertion of the peroneus brevis. The smooth contours of these ossicles, in contrast to a fracture, should distinguish them from an acute injury. 
The blood supply to the proximal fifth metatarsal in the meta-diaphyseal junction has been implicated as the leading factor in the development of a delayed union or nonunion in fractures of the proximal fifth metatarsal. It is similar to the other metatarsals in that a single nutrient artery enters from the medial cortex at the junction of the proximal and middle third of the diaphysis and supplies the shaft. Secondary epiphyseal and metaphyseal arteries supply the base and tuberosity. The metaphyseal-diaphyseal junction represents a watershed region between those two blood supplies. 
In the rare instance where open reduction of or access to the proximal tuberosity is necessary, great care should be taken during the approach. The sural nerve, the insertion of the peroneus brevis, and the insertion of the peroneus tertius, as well as the lateral anchor for the extensor retinaculum, are all within the surgical margins. Damage to these structures should be avoided. 
Fractures of the fifth metatarsal account for approximately 68% of all metatarsal fractures.263 Injuries to the fifth metatarsal are usually discussed separately from the other metatarsals because of the different venues where these injuries are seen. These fractures are separated roughly into two groups: Proximal base fractures and distal spiral or dancer’s fractures. Proximal fifth metatarsal fractures are further divided by the location of the fracture and the presence of prodromal symptoms. The relative frequency of these fractures was shown in a busy general orthopedic practice to be approximately 93% zone 1, 4% zone 2, and 3% zone 3 (Fig. 62-37). 
Figure 62-37
Three zones of proximal fifth metatarsal fracture.
 
Zone 1: Avulsion fracture. Zone 2: Fracture at the metaphyseal-diaphyseal junction. Zone 3: Proximal shaft fracture.
Zone 1: Avulsion fracture. Zone 2: Fracture at the metaphyseal-diaphyseal junction. Zone 3: Proximal shaft fracture.
View Original | Slide (.ppt)
Figure 62-37
Three zones of proximal fifth metatarsal fracture.
Zone 1: Avulsion fracture. Zone 2: Fracture at the metaphyseal-diaphyseal junction. Zone 3: Proximal shaft fracture.
Zone 1: Avulsion fracture. Zone 2: Fracture at the metaphyseal-diaphyseal junction. Zone 3: Proximal shaft fracture.
View Original | Slide (.ppt)
X

Fifth Metatarsal Fracture Injury Mechanisms

Although injury to this area does occur with motor vehicle collisions, the majority of injuries are related to twisting of the foot or a fall from a standing height.89 An avulsion fracture, or zone 1 injury at the base of the fifth metatarsal usually occurs from an indirect load. Sudden inversion of the hindfoot with weight on the lateral metatarsal places tension along the insertion of the lateral band of the plantar aponeurosis which inserts into the proximal base of the fifth metatarsal causing disruption of the bony cortex. 
Zone 2 injuries are true Jones fractures. They represent an acute injury caused by adduction of the forefoot resulting in a fracture at the proximal metaphyseal–diaphyseal junction of the bone. The fracture propagates from the lateral aspect of the proximal metatarsal toward the four to five articular surfaces. It can progress proximally into the metatarsal-cuboid joint and exhibit comminution. It is a fracture due mainly to tensile stress along the lateral border of the metatarsal. 
The third type of fracture seen in the proximal fifth metatarsal is now referred to as a proximal diaphyseal stress fracture. These are relatively rare and seen mainly in athletes. It occurs in the proximal 1.5 cm of the shaft of the metatarsal. Repetitive cyclic loads, as seen in high-level athletics, appear to be the underlying mechanism for these injuries. The fracture is induced by tensile forces resulting in microfractures at the lateral cortex. Continued loading propagates the fracture medially. 
The remainder of fifth metatarsal fractures not caused by a direct blow has been termed dancer’s fracture. The usual pattern is a spiral, oblique fracture of the shaft progressing from distal-lateral to proximal-medial. The mechanism of injury is typically a rotational force being applied to the foot while it is axially loaded in a plantarflexed position. The usual method is by rolling over the outer border of the foot. 

Signs and Symptoms and Imaging of Fifth Metatarsal Fractures

Fractures of the fifth metatarsal typically show pain, swelling, and tenderness on the outside of the foot. Patients usually complain about difficulties with walking. Bruising may occur following direct trauma. To delineate those injuries which require further radiologic investigation, the Ottawa Foot Rules as an extension of the Ottawa Ankle Rules should be followed. They have been found to be 100% sensitive and 79% specific for the identification of fifth metatarsal fractures.89 
Radiographic evaluation is critical to assess fifth metatarsal fractures for consideration of treatment options. Three views (AP, lateral, and oblique) are mandatory to judge shortening, deviation, angulation, and displacement.214 If clinical findings are suggestive of a fracture at the base of the fifth metatarsal but radiographs of the foot appear normal, an AP radiograph of the ankle that includes the proximal fifth metatarsal is recommended to rule out a tuberosity avulsion fracture located at the tip of the tuberosity proximal to its expanded portion.259 Additional information regarding intra-articular fracture lines and fragments can be obtained through computed tomography. MRI can provide additional information related to soft tissue injuries. 

Fifth Metatarsal Fracture Classification

The OTA classification of fifth metatarsal fractures permits a detailed description of the fracture pattern but is not commonly used.207 Fractures of the fifth metatarsal under this system observe the format: (87(S)-_ _._). 
Fractures of the proximal diaphysis of the fifth metatarsal are given special attention in the literature and have been identified for their potential to develop into a delayed union or nonunion. Therefore, Torg’s classification333 is based on clinical and radiographic findings according to the healing status. Type I: acute fractures without a previous history of trauma and with a narrow fracture line. Type II: delayed fractures with a history of previous trauma and periosteal changes, widening of the fracture line and radiolucency of the fracture site. Type III: nonunited fractures with a history of repetitive trauma, periosteal bone formation and replacement of the medullar canal by sclerotic bone. 
Stewart’s system321 classifies proximal fifth metatarsal fractures based upon the relationship of the fracture line to the articular surface, the fracture type, and the fracture site. Type I: Extra-articular fractures between the metatarsal base and diaphysis, Type II: Intra-articular avulsion fractures of the metatarsal base, Type III: Extra-articular avulsion fractures of the base, Type IV: Intra-articular, comminuted fractures, Type V: Extra-articular partial avulsion of the metatarsal base. 
Dameron79 in 1975 noted differences in healing related to the fracture location in relationship to the peroneus brevis tendon. Therefore, three anatomic zones were described, Zone 1: Tuberosity-avulsion, Zone 2: Metaphyseal-diaphyseal junction, and Zone 3: Proximal diaphyseal stress fractures. Currently, Zone 2 fractures are commonly referred to as “Jones fractures” (Fig. 62-37). 

Fifth Metatarsal Fracture Treatment Options

Nonoperative Treatment.
Treatment options vary according to the fracture zones. The conclusion is that Zone 1 injuries as well as distal fractures can be treated quite well by closed means such as with a stiff soled shoe, cast or fracture boot. Nonoperatively treated nondisplaced avulsion fractures of the tuberosity of the fifth metatarsal tend to heal uneventfully within 3 to 12 weeks in nearly all patients with few residual symptoms up to 1 year.89,101 
The treatment of acute injuries of the proximal diaphysis, in Zone 2, is controversial. Part of the problem appears to be the mixing of acute and chronic injuries in earlier series. These act as two different fracture populations wherein those with prodromal symptoms are more likely to have difficulty healing and should be considered as Zone 3 injuries. Proximal diaphyseal fractures are best initially treated the same whether the injury is truly acute or there is a history of prodromal symptoms. Both are placed in a short-leg non-weight-bearing casts for 6 weeks. The presence of prodromal symptoms will determine when weight-bearing activities are then allowed. At 6 weeks, acute fractures (no prodromal symptoms) are changed to a removable short-leg walker and weight bearing is allowed to progress as tolerated. When full asymptomatic weight bearing occurs, physical therapy can begin as well as a return to sporting activities. This takes up to 10 weeks in most cases. Those fractures that present with a history of localized pain with activity (stress fractures) are left in a non-weight-bearing cast for an additional 8 weeks. At that time, reexamination of the fracture is done to look for clinical and radiographic signs of healing. Radiographically, dissolution of the sclerotic margins of the fracture and reconstitution of the medullary canal are signs of active healing. Lack of pain with direct palpation of the fracture site and with motion of the distal metatarsal can be seen clinically as healing occurs. Non-weight-bearing casting is usually continued for a full 3 months. 
Zone 3 injuries are those that occur distal to the proximal tuberosity and present with prodromal symptoms before complete fracture occurs. It is this particular fracture that poses problems because of its tendency toward nonunion. Successful treatment of this fracture pattern requires more aggressive treatment than that used for other fracture patterns in the fifth metatarsal. Initial treatment ranges from casted non-weight-bearing for up to 3 months to surgical intervention with grafting and internal compression. In the fractures with a short period of localized pain with activity before diagnosis, non-weight-bearing casting offers results comparable to surgery. 
Dancer’s fractures of the distal shaft of the fifth metatarsal usually heal well with nonoperative cast immobilization (Fig. 62-38) (Table 62-17). 
Figure 62-38
 
(A) Anterior–posterior and oblique radiographs of a fifth metatarsal dancer’s fracture treated nonoperatively at injury, (B) at 3 months follow-up, and (C) at final follow-up 9 months post injury.
(A) Anterior–posterior and oblique radiographs of a fifth metatarsal dancer’s fracture treated nonoperatively at injury, (B) at 3 months follow-up, and (C) at final follow-up 9 months post injury.
View Original | Slide (.ppt)
Figure 62-38
(A) Anterior–posterior and oblique radiographs of a fifth metatarsal dancer’s fracture treated nonoperatively at injury, (B) at 3 months follow-up, and (C) at final follow-up 9 months post injury.
(A) Anterior–posterior and oblique radiographs of a fifth metatarsal dancer’s fracture treated nonoperatively at injury, (B) at 3 months follow-up, and (C) at final follow-up 9 months post injury.
View Original | Slide (.ppt)
X
 
Table 62-17
Fifth Metatarsal Fractures
View Large
Table 62-17
Fifth Metatarsal Fractures
Nonoperative Treatment
Indications Relative Contraindications
Acute nondisplaced or minimally displaced fractures Displaced fractures
Avulsion fractures (Zone 1) Persistent nonunions
Zone 2 fractures
Acute Zone 3 fractures Zone 3 fractures with prodromal symptoms
X
Operative Treatment of Fifth Metatarsal Fractures.
Surgical treatment has been considered to expedite the healing process in highly active individuals with an acute Jones fractures. It is also advocated when there is greater than 2 mm displacement, and in fractures involving the fifth TMT joint to restore the joint surface alignment with open reduction. Open reduction and stabilization of these injuries has been very satisfying. The reduced fragments can be held in place with mini-fragment screws that do not cross the joint or K-wires that can cross the joint. 
In the case of significant fracture displacement at the time of presentation or failure of nonoperative management, operative reduction and fixation is also advocated. Best results are obtained with open debridement of the nonunion site and cancellous bone grafting. Rigid intramedullary compression of the fracture is used to stabilize the injury. 
Operative contraindications may include patient factors, vascular compromise, local infection, or medical instability. 
Axial compression is effectively achieved by the tension band principle in avulsion fractures of the fifth metatarsal (Fig. 62-39). Intramedullary screw fixation utilizing a malleolar bone screw is widely used for proximal fractures of the fifth metatarsal (Fig. 62-40). Open reduction and plate fixation is best suited for comminuted or displaced oblique shaft fractures (Fig. 62-41). 
Figure 62-39
Tension band wiring after displacement of a fifth metatarsal base fracture.
 
A: Two weeks after injury progressive fracture displacement can be seen on the oblique radiograph. B: After screw fixation and tension band wiring the fracture is reduced.
A: Two weeks after injury progressive fracture displacement can be seen on the oblique radiograph. B: After screw fixation and tension band wiring the fracture is reduced.
View Original | Slide (.ppt)
Figure 62-39
Tension band wiring after displacement of a fifth metatarsal base fracture.
A: Two weeks after injury progressive fracture displacement can be seen on the oblique radiograph. B: After screw fixation and tension band wiring the fracture is reduced.
A: Two weeks after injury progressive fracture displacement can be seen on the oblique radiograph. B: After screw fixation and tension band wiring the fracture is reduced.
View Original | Slide (.ppt)
X
Figure 62-40
 
Full weight-bearing imaging at 6 months follow-up after intramedullary screw fixation of a Zone 3 fifth metatarsal shaft fracture. A: AP view. B: Lateral view.
Full weight-bearing imaging at 6 months follow-up after intramedullary screw fixation of a Zone 3 fifth metatarsal shaft fracture. A: AP view. B: Lateral view.
View Original | Slide (.ppt)
Figure 62-40
Full weight-bearing imaging at 6 months follow-up after intramedullary screw fixation of a Zone 3 fifth metatarsal shaft fracture. A: AP view. B: Lateral view.
Full weight-bearing imaging at 6 months follow-up after intramedullary screw fixation of a Zone 3 fifth metatarsal shaft fracture. A: AP view. B: Lateral view.
View Original | Slide (.ppt)
X
Figure 62-41
 
A and B: AP and oblique radiographs of a displaced fifth metatarsal shaft fracture. C and D: AP and oblique views after open reduction and plate osteosynthesis. E and F: AP and oblique views of a healed fracture at 12 months.
A and B: AP and oblique radiographs of a displaced fifth metatarsal shaft fracture. C and D: AP and oblique views after open reduction and plate osteosynthesis. E and F: AP and oblique views of a healed fracture at 12 months.
View Original | Slide (.ppt)
A and B: AP and oblique radiographs of a displaced fifth metatarsal shaft fracture. C and D: AP and oblique views after open reduction and plate osteosynthesis. E and F: AP and oblique views of a healed fracture at 12 months.
View Original | Slide (.ppt)
Figure 62-41
A and B: AP and oblique radiographs of a displaced fifth metatarsal shaft fracture. C and D: AP and oblique views after open reduction and plate osteosynthesis. E and F: AP and oblique views of a healed fracture at 12 months.
A and B: AP and oblique radiographs of a displaced fifth metatarsal shaft fracture. C and D: AP and oblique views after open reduction and plate osteosynthesis. E and F: AP and oblique views of a healed fracture at 12 months.
View Original | Slide (.ppt)
A and B: AP and oblique radiographs of a displaced fifth metatarsal shaft fracture. C and D: AP and oblique views after open reduction and plate osteosynthesis. E and F: AP and oblique views of a healed fracture at 12 months.
View Original | Slide (.ppt)
X
Surgical Technique.
The patient is positioned supine on a radiolucent table with a bump under the hip of the surgical side to help internal rotation of the foot. A mini-fluoroscopy unit can be positioned at the end of the operating table, or standard fluoroscopy located opposite the surgical extremity. The surgical approach is along the lateral border of the fifth metatarsal just above the adductor minimi muscle. The proximal tip of the tuberosity is identified as well as the fracture or nonunion site. 
For intramedullary screw fixation, the incision should be made proximal to the fifth metatarsal base between the peroneus brevis and longus tendons. A guidewire should be started in a high and inside position at the base of the fifth metatarsal. Intraoperative fluoroscopy is helpful for positioning the guidewire down the shaft. A cannulated 3.5-mm or larger screw should be utilized to tightly fit the metatarsal canal. 
For delayed unions or nonunions, the fracture site should be completely opened with osteotomes or a rongeur. The medullary canal should be cleared of any sclerotic debris. The void created by the debridement needs to be completely filled with autograft. Axial compression can be obtained with a cannulated compression screw equal to or greater than 3.5-mm in diameter that will tightly fit the metatarsal canal. Using fluoroscopic imaging the screw is introduced through the proximal tuberosity and across the fracture. According to cadaver studies, the insertion point for intramedullary fixation is 1cm dorsal to the palpable inferior margin of the proximal tuberosity and just medial to the peroneus brevis insertion. The drill, or guide pin, should proceed in a plantar direction at an angle 7 degrees off the plantar surface of the foot with the ankle in neutral160 (Table 62-18). 
 
Table 62-18
ORIF of Fifth Metatarsal Fractures
View Large
Table 62-18
ORIF of Fifth Metatarsal Fractures
Surgical Steps
  •  
    Incision proximal to the fifth metatarsal base between the peroneus brevis and longus tendons
  •  
    Positioning of a guidewire down the shaft by utilizing fluoroscopy
  •  
    For delayed unions or nonunions, the fracture site should be completely opened with osteotomes or a rongeur.
  •  
    Filling the void created by the debridement with autograft
  •  
    Internal fixation by cannulated compression screw 3.5 mm or larger to tightly fit the metatarsal canal
X
Surgical stabilization does not permit early return to activity with these fractures. Short-leg casting and protected weight bearing similar to the treatment of early zone 3 injuries are necessary to have the best chance of healing. 
Potential Pitfalls and Preventative Measures.
The sural nerve is only 5 mm or so dorsal to the screw insertion site and should be shielded from injury. The screw should engage the cortical bone of the distal fragment without distorting metatarsal alignment. 
Complications from this injury if treated properly are rare. For Zone 1 fractures, nonunion can occur but it is usually asymptomatic and requires no intervention. There are reported incidences of pain from sural nerve entrapment or TMT joint pain with nonunion. In these instances, the fracture fragments should be excised. If the symptomatic nonunion is large enough to involve the insertion of the peroneus brevis, it is large enough for fixation and cancellous bone grafting using a 3.5- or 4.0-mm lag screw. 
We believe the reported incidence of nonunion among Zone 2 and 3 injuries is more the result of the method of treatment. These fractures need a period of immobilized non-weight-bearing to minimize complications. Surgical failures result from resuming activity too soon, inadequate grafting, and/or incomplete debridement of the sclerotic medullary canal. Deformity of the fifth metatarsal can result from selection of an improper screw angle leading to unicortical gaping resulting in prolonged healing, pain and bunionette deformity due to abnormal shoe contact.12,15 
Surgical treatment utilizing screw fixation of Jones fractures leads to a 95% union rate compared to 66% in nonoperative treatment, with earlier radiographic healing, and earlier return to sport.229 For avulsion fractures screw fixation was found to be better than tension band wiring.152 

Management of Expected Adverse Outcomes and Unexpected Complications

Complications associated with surgical treatment of Jones fractures commonly include soft tissue irritation from the prominent screw head, bending of the screw, penetration of the distal cortices, refracture, delayed union, and nonunion.195 Soft tissue irritation can be prevented by proper screw placement and hardware removal following healing. Nonunion and refracture are usually prevented by initiating weight bearing only after radiographic healing has occurred. 

Author’s Preferred Treatment

 
 

An algorithm outlining the authors’ preferred treatment of fifth metatarsal fractures is presented in Figure 62-42.

 
Figure 62-42
Authors’ preferred treatment algorithm for fifth metatarsal fractures.
Rockwood-ch062-image042.png
View Original | Slide (.ppt)
X

Sesamoid Fractures

The sesamoid complex performs a crucial role in the function of the first metatarso-phalangeal joint by enhancing the pulley action of the medial or lateral head of the flexor hallucis brevis tendon and subsequently the function of the flexor hallucis longus and transmits up to 50% of the body weight under normal circumstances, which increases to approximately 300% during push off.82,215 Therefore, sesamoids are subjected to both impact loading and shear stresses, and injuries involving the sesamoids may occur in a number of sports. The medial or tibial sesamoid typically bears more weight than the lateral or fibular sesamoid and is more likely to be injured.42 The hallucal sesamoid complex is involved in 9% of foot and ankle injuries and in 1.2% of running injuries.165 

Assessment and Classification of Sesamoid Fractures

Acute fractures of the sesamoids occur because of excessive cyclic weight-bearing loads, significant trauma resulting in a hyper-dorsiflexion injury to the metatarso-phalangeal joint of the great toe, or direct trauma. Sesamoid fractures may be associated with additional fractures of the first ray and traumatic dislocations of the first metatarso-phalangeal joint. 
Injuries to the sesamoid complex lead to impairment of hallux plantar flexion and should not be underestimated. These fractures are often characterized by pain and tenderness over the symptomatic sesamoid that is worsened by passive dorsiflexion of the great toe, ambulation, and running. Patients sometimes tolerate these fractures by ambulating on the lateral aspect of the foot. 
Imaging for the sesamoidal complex should begin with the standard three views of the foot along with a sesamoidal axial view or skyline view.139,256 The sesamoids are evaluated for their position, areas of irregularity, bipartite/multipartite presentation, and fracture lines. Images of the contralateral foot for comparison may be useful. When no obvious fracture lines are visible, but the suspicion of a fracture persists, CT, MRI, or a three phase 99mTc-bone scan can help to differentiate acute fractures from sesamoiditis or bipartite/multipartite sesamoids. Computed tomography should include coronal and sagittal 1- to 2-mm slices (Fig. 62-43). 
Figure 62-43
 
A: A bipartite medial sesamoid (yellow arrows indicate rounded edges of the bipartite bone). B: In comparison an acute sesamoid fracture (white arrows indicate fracture zone). C: A “Skyline view” of the sesamoids is used to identify sesamoid fracture displacement.
A: A bipartite medial sesamoid (yellow arrows indicate rounded edges of the bipartite bone). B: In comparison an acute sesamoid fracture (white arrows indicate fracture zone). C: A “Skyline view” of the sesamoids is used to identify sesamoid fracture displacement.
View Original | Slide (.ppt)
Figure 62-43
A: A bipartite medial sesamoid (yellow arrows indicate rounded edges of the bipartite bone). B: In comparison an acute sesamoid fracture (white arrows indicate fracture zone). C: A “Skyline view” of the sesamoids is used to identify sesamoid fracture displacement.
A: A bipartite medial sesamoid (yellow arrows indicate rounded edges of the bipartite bone). B: In comparison an acute sesamoid fracture (white arrows indicate fracture zone). C: A “Skyline view” of the sesamoids is used to identify sesamoid fracture displacement.
View Original | Slide (.ppt)
X
Sesamoid fractures are most commonly classified as acute or stress fractures. Sesamoid fractures types are classified as simple or stellate fractures. Stellate-fractures usually are comminuted and bear a higher potential for osteonecrosis based on the arterial blood supply. Each sesamoid is generally supplied by a single sesamoid artery with most of the blood supply coming from a proximal and plantar direction.270 This lack of substantial secondary blood supply may help to explain much of the sesamoid pathology, including osteonecrosis and nonunion.82 

Pathoanatomy and Applied Anatomy Relating to Sesamoid Fractures

In the first ray of the foot, there are two constant sesamoids, which lie beneath the first metatarsal head and are imbedded within the plantar plate. They are located centrally and plantar to the first metatarsal head and are referred to as medial (tibial) and lateral (fibular) sesamoids. A third (inconstant) sesamoid develops inferior to the hallux interphalangeal joint. The medial sesamoid is larger, ovoid, and elongated. It is encased within the medial head of the flexor hallucis brevis tendon. The lateral sesamoid is smaller, more circular, and surrounded by the lateral head of the flexor hallucis brevis tendon. Portions of the adductor and abductor hallucis tendons also insert on the sesamoids. The two sesamoids are connected by a thick inter-sesamoid ligament, which makes up the central component of the plantar plate of the first metatarso-phalangeal joint. The larger size of the medial/tibial sesamoid predisposes it to more pathology. 
The blood supply to each sesamoid is provided by its own individual artery and stems from the medial plantar artery and the plantar arch. Both sesamoids are less well vascularized distally, which may result in osteonecrosis or nonunion after fracture. Because of the predominantly plantar vascular supply, dorsal or medial incisional approaches are safer. 

Sesamoid Fracture Treatment Options

Nonoperative Treatment.
Nonoperative treatment is usually the initial management for hallux sesamoid fractures. It begins with a period of activity modification, with immobilization in a cast, or an orthotic device. Most patients who have a sesamoid fracture can remain ambulatory with just a few simple changes to weight bearing and footwear. Reducing the load to the sesamoid during healing can be achieved by utilization of a forefoot off-loading shoe, a short-leg cast, or a cam walker with a rocker sole. This period of off-loading may last 6 to12 weeks. 
Insufficient treatment of a sesamoid fracture can lead to prolonged pain and nonunion. Symptomatic nonunion seems to be a problem in up to 30% after nonoperative treatment.32,93 In our clinical practice nonunion might result in persistent patient disability and can prevent return to previous level of activity or return to work after work-related injury of the sesamoid. Some authors presume that sesamoid fractures do not heal by true osseous union, but instead heal by forming a fibrous bridge or nonunion.93 
Operative Treatment.
Operative treatment is recommended for displaced sesamoid fractures and nondisplaced sesamoid fractures that do not respond to at least 3 months of nonsurgical care. Percutaneous screw fixation may be carried out as a day case under general or regional anesthesia.39,221 The patient is placed supine on a radiolucent OR table to allow access for fluoroscopy. The great toe is kept in maximal dorsiflexion to stabilize the sesamoids and bring them to a more superficial position. Axial and lateral views are obtained using fluoroscopy. A stab incision is made over the distal part of the sesamoid and, a 1-mm K-wire is inserted under fluoroscopy control aiming for the axial and lateral mid-diameter. A second K-wire of the same length is then used to facilitate measurement for the correct screw length. A 2-mm cannulated drill is inserted over the guide wire and used to drill both cortices. A self-tapping Herbert or Barouk screw is inserted from distal to proximal in order to engage both cortices for maximum compression. Any prominence of the distal thread should be avoided. 
After percutaneous screw fixation, patients are allowed to begin weight bearing as tolerated with crutches at 7 to 10 days followed by full weight bearing without aids as tolerated. 
Sesamoidectomy for hallucal sesamoid fractures is indicated in patients who have failed to respond to conservative measures 3 months or more after injury.42,285 Sesamoidectomy is performed as either a partial or total resection. 
The patient is positioned supine on a radiolucent OR table. Medial sesamoid resection is performed through a medial approach and lateral sesamoid resection is performed through a dorsal approach. The medial approach begins with a 3 to 4 cm incision medially extending from the proximal flare of the metatarsal head to the midshaft of the proximal phalanx. Care is taken to protect the plantar digital nerve. A linear capsulotomy is performed just inferior to the abductor hallucis tendon, and the medial sesamoid is dissected from the flexor hallucis brevis, which should be persevered. Following excision, water-tight closure of the capsule is performed with multiple 2-0 absorbable interrupted sutures. 
Lateral sesamoid resection is performed through a dorsal approach. A 3-cm incision is created in the first interspace and continued to the sesamoid-first metatarsal articulation. The first structure encountered is the deep transverse intermetatarsal ligament, which is transected. Care should be taken to protect the common digital nerve. The adductor hallucis tendon is detached from the base of the proximal phalanx and the lateral sesamoid and retracted. A lateral capsulotomy is performed and the sesamoid is excised taking great care to avoid damaging the flexor hallucis longus tendon. Following excision, the adductor tendon and capsule are anatomically repaired. 
Plantar approaches should be avoided due to the risk of creating a painful plantar scar and plantar keratosis. The incision is medially based along the metatarso-phalangeal joint to allow both intra-articular and extra-articular access to the medial/tibial sesamoid. Careful dissection along the plantar plate will expose the medial sesamoid for excision or fixation (Fig. 62-44). 
Figure 62-44
Surgical approaches to the medial (A) and lateral (B) sesamoids.
 
1, flexor hallucis longus tendon; 2, lateral sesamoid bone;3, medial sesamoid bone; EHL, extensor hallucis longus tendon; EDL, extensor digitorum longus tendon of the second toe.
1, flexor hallucis longus tendon; 2, lateral sesamoid bone;3, medial sesamoid bone; EHL, extensor hallucis longus tendon; EDL, extensor digitorum longus tendon of the second toe.
View Original | Slide (.ppt)
Figure 62-44
Surgical approaches to the medial (A) and lateral (B) sesamoids.
1, flexor hallucis longus tendon; 2, lateral sesamoid bone;3, medial sesamoid bone; EHL, extensor hallucis longus tendon; EDL, extensor digitorum longus tendon of the second toe.
1, flexor hallucis longus tendon; 2, lateral sesamoid bone;3, medial sesamoid bone; EHL, extensor hallucis longus tendon; EDL, extensor digitorum longus tendon of the second toe.
View Original | Slide (.ppt)
X
Minimal invasive fixation of the sesamoids can be performed by stabilizing the sesamoids in maximal dorsiflexion. A stab incision is made over the distal part of the affected sesamoid followed by insertion of a guide wire under radiologic control into the axial and lateral mid-diameter of the sesamoid. A cannulated screw is inserted over the guide-wire from distal to proximal in order to engage both cortices. The distal thread should be buried within the sesamoid.39 
After sesamoid resection, patients are allowed to begin weight bearing as tolerated in a postoperative shoe using crutches for 7 to 10 days followed by a removable walking boot for additional 2 weeks. 

Outcomes and Complications

Percutaneous screw fixation for hallucal sesamoid fractures can result in return to activity at the 12 week time-point and significant improvement in the AOFAS score.39 Sesamoidectomy leads to excellent pain relief postoperatively. Ninety percent of the patients are able return to work on average by 12 weeks.32,306 
Percutaneous screw fixation can result in wound infection and stiffness of the great toe. Sesamoidectomy can lead to wound infections and injury to the plantar digital nerve. Symptomatic hallux valgus deformity after excision of the medial sesamoid, and metatarsalgia and flexor hallucis tenosynovitis after lateral sesamoidectomy through a dorsal incision have been observed. Intrinsic minus/cock-up deformities have been reported with excision of both the fibular and tibial sesamoids; therefore, excision of both is no longer recommended.82 

Author’s Preferred Treatment

 
 

Treatment of sesamoidal fractures should vary according to fracture type and location. Minimally displaced fractures are treated nonoperatively by local and systemic pain medication, icing, and initial immobilization in slight plantar flexion to relax the flexor hallucis brevis tendon followed by modification of foot wear. Sesamoidal fractures with only two large fragments can be fixed utilizing 2.0-mm screws. Dislocated fragments not treatable by screw fixation are usually removed by excision of the distal pole. Persistent painful nonunions and comminuted fractures of a single sesamoid are commonly treated by sesamoidectomy. The flexor hallucis brevis tendon is augmented when necessary to prevent deformity.

Fractures of the Toes

Digital fractures are the most common forefoot injuries and often they are underappreciated. Digital fractures occur with an incidence ranging from 14.0 to 39.6 patients per 10,000 persons per year.342 The hallux is involved in approximately 14 to 38%, but the proximal phalanx of the fifth toe is the one most commonly injured in approximately 30% of the cases.314,342 Fracture of the proximal phalanx of any toe is much more common than fracture of the middle or terminal phalanx. Fractures of the lesser toes are usually uncomplicated events, causing immediate pain and discomfort to the patient but few long-term functional problems.227 
The great toe is of substantial importance for maintaining body balance and supporting the body when changing direction during standing, walking, and running. Consequently, displaced or unstable fractures of the proximal phalanx of the great toe must be carefully reduced to avoid dysfunction of the hallux interphalangeal joint or metatarso-phalangeal joint.4,78 

Assessment and Classification of Phalangeal Injuries

Two mechanisms are responsible for the majority of phalangeal fractures. A direct blow such as a heavy object dropped onto the foot usually causes a transverse or comminuted fracture. Stubbing injury is the most common cause, occurring in up to 75% of the cases,342 and consisting of axial loading with a secondary varus or valgus force resulting in a spiral or oblique fracture pattern. This mechanism is most likely to produce clinical deformity and lead to fracture dislocations of the interphalangeal joint. Indirect mechanisms that apply twisting forces to the fixed forefoot are less common.314 
Patients who have digital fractures may complain of tenderness and pain with ambulation and present with swelling, local pain upon palpation, ecchymosis, and subungual hematoma, particularly in combination with distal phalangeal fractures.195 Also, difficulty with shoe wear and pain with ambulating bare foot or with supple shoes are common. Occasionally, the patient will relate a history of acute deformity with spontaneous or manipulated reduction. Further examination should identify any vascular or neurologic deficit, soft tissue injuries, and compartment syndrome. 
Radiographic examination is important to differentiate between a sprain, dislocation, and/or fracture and to assess alignment. Standard AP and lateral radiographs of the forefoot should be obtained. 
The OTA fracture classification is the only one that allows an accurate description of the fracture pattern involved.208 The designation of phalangeal fractures under this system observes the format (88()-_ _._) in a fashion similar to the metatarsals of the foot. To denote which ray the classification refers to, an alpha numeric identifier should be placed in parentheses beside the major designation: first toe (T1/2), second toe (N1/2/3), third toe (M1/2/3), fourth toe (R1/2/3), fifth toe (L1/2/3). The second numeric designation denotes whether it is the proximal (1), middle (2), or distal (3) phalanx that is involved. 
The alpha subclassification of a phalanx fracture represents fracture complexity while the numeric subgroupings denote fracture position and pattern. Group A denotes extra-articular and simple diaphyseal fractures. Group B involves partial articular and diaphyseal wedge fractures. Group C involves complex articular or diaphyseal shaft fractures. The first numeric sub grouping denotes area of involvement: Proximal metaphyseal (1), diaphyseal (2), and distal metaphyseal (3). The second designation is for fracture pattern designation and can vary depending on the group and first numeric designation. There are no data to show the effectiveness of this classification with regard to determining care or predicting outcome with these fractures (Fig. 62-45). 
Rockwood-ch062-image045a.png
View Original | Slide (.ppt)
Rockwood-ch062-image045b.png
View Original | Slide (.ppt)
Rockwood-ch062-image045c.png
View Original | Slide (.ppt)
Figure 62-45
OTA classification for phalangeal fractures (88-__._)
Rockwood-ch062-image045a.png
View Original | Slide (.ppt)
Rockwood-ch062-image045b.png
View Original | Slide (.ppt)
Rockwood-ch062-image045c.png
View Original | Slide (.ppt)
X

Fractures of the Toes Treatment Options

Nonoperative Treatment.
Fractures of the phalanges are uniformly painful and generally treated symptomatically by immobilization and early return to function. All nondisplaced fractures, regardless of their articular involvement, can be treated with a stiff-soled shoe and protected weight bearing for 2 to 3 weeks with advancement as tolerated. The use of a buddy taping technique between adjacent toes may improve pain relief and help stabilize potentially unstable fracture patterns.314 
Fractures with clinical deformity require reduction. Closed reduction is usually adequate and the result is usually stable. Reduction is obtained with gravity traction and axial realignment. With the great toe, stabilizing the proximal fragment for reduction is usually no problem. For the lesser toes, placing a pen or pencil in the web space adjacent to the apex of the fracture can provide a rigid surface to allow three-point bending pressure to realign the fracture.227 With extra-articular fractures, it is important to restore axial alignment and rotation. Axial shortening does not adversely affect function. With extra-articular fractures, the adequacy of the reduction is determined by the clinical appearance of the toe in relation to its neighbors and not its radiographic appearance. The nail bed should be rotated into a position similar to that of adjacent toes, and the toe’s axial position should be aligned with the normal cascade of the other toes. Once satisfactory clinical alignment is obtained, the toe can be buddy taped to its neighbor for added stability. Lamb’s wool or other soft nonabsorbent material should be placed in the web space to minimize maceration of the soft tissues. Sometimes with the great toe, short-term immobilization in a plaster splint may be necessary to hold the reduction (Fig. 62-46). 
Fracture healing at 6-month follow-up (C—AP view; D—oblique view).
View Original | Slide (.ppt)
Figure 62-46
Nonoperative treatment of a minimally displaced fracture of the proximal and distal phalanges of the great toe (A—AP view; B—oblique view).
Fracture healing at 6-month follow-up (C—AP view; D—oblique view).
Fracture healing at 6-month follow-up (C—AP view; D—oblique view).
View Original | Slide (.ppt)
X
Operative Treatment.
Operative reduction is reserved for those rare phalangeal fractures where gross instability or persistent intra-articular discontinuity is present. This problem usually arises when there is an intra-articular fracture of the proximal phalanx of the great toe or multiple fractures of the lesser toes. A grossly unstable fracture of the proximal phalanx of the great toe should be reduced and can be fixed with percutaneous K-wires or mini-fragment screws (Fig. 62-47). Unstable fractures, particularly intra-articular fractures’ despite an adequate reduction, should be reduced and percutaneously pinned in place to avoid late malalignment (Fig. 62-48). Operative contraindications may include patient factors, vascular compromise, local infection, or medical instability. 
Figure 62-47
Mini screw fixation of a displaced intra-articular fracture of the proximal phalanx of the great toe (AP view).
Rockwood-ch062-image047.png
View Original | Slide (.ppt)
X
Figure 62-48
Open grade 2 distal phalanx fracture of the great toe (arrow) in an 82-year-old woman (A—AP view; B—oblique view.).
 
Postoperative imaging with AP (C) and oblique view (D) after irrigation and debridement following open reduction and K-wire fixation with temporary pinning across the interphalangeal joint. The K-wire was removed at 6 weeks.
Postoperative imaging with AP (C) and oblique view (D) after irrigation and debridement following open reduction and K-wire fixation with temporary pinning across the interphalangeal joint. The K-wire was removed at 6 weeks.
View Original | Slide (.ppt)
Figure 62-48
Open grade 2 distal phalanx fracture of the great toe (arrow) in an 82-year-old woman (A—AP view; B—oblique view.).
Postoperative imaging with AP (C) and oblique view (D) after irrigation and debridement following open reduction and K-wire fixation with temporary pinning across the interphalangeal joint. The K-wire was removed at 6 weeks.
Postoperative imaging with AP (C) and oblique view (D) after irrigation and debridement following open reduction and K-wire fixation with temporary pinning across the interphalangeal joint. The K-wire was removed at 6 weeks.
View Original | Slide (.ppt)
X
Potential Pitfalls and Preventative Measures.
If a fracture is identified in the presence of nail bed bleeding or laceration, the fracture should be treated as an open fracture, and the nail bed should be decompressed and debrided.195 
Complications arise from these injuries in the form of continued abnormal alignment. This can provide problems with shoe fit and wear as well as soft corn lesions between the toes caused by bony prominences. Rotational deformities will cause abnormal joint function and can result in progressive deformity. On occasion, two pins may be required to stabilize a grossly unstable fracture. Late deformities, if symptomatic, should be treated with refracture and pinning. Sometimes small chip fractures do not heal. If they are prominent and symptomatic, they can be excised. Persistent pain as the result of malunited fractures and post-traumatic arthritis can be treated by arthrodesis or resection arthroplasty of the affected joint. 

Author’s Preferred Treatment

 
 

An algorithm outlining the authors’ preferred treatment for phalangeal fractures is presented in Figure 62-49.

 
Figure 62-49
Authors’ preferred treatment algorithm for phalangeal fractures.
Rockwood-ch062-image049.png
View Original | Slide (.ppt)
X

High-Energy Injuries: “The Multiple Injured Foot”

Acute injuries with high-energy impact on the foot often result from road accidents,156,287 falls from height, and crush injuries.246 Furthermore, major injuries to the foot are increasingly seen as a result of combat.171 These high-energy injuries usually lead to a so-called “multiple injured foot.” Severe combined soft tissue injuries and osseo-ligamentous instability are common and require a staged approach with the goal of functional reconstruction of the foot. Open injuries are common and require accurate care. To properly address all soft tissue and musculoskeletal problems a thorough examination during the primary assessment is necessary to determine the full extent of the injury. As life-threatening injuries attract most of the physician’s attention during the acute phase of trauma management, injuries to the distal extremities are often of secondary priority. Often ligamentous bony or soft tissue injuries are overlooked or identified on a delayed basis. Insufficiently addressed injuries of the soft tissue envelope, but also of the static and dynamic components of the osseo-ligamentous complex can lead to impaired functional outcome, gait disturbance, and persistence of pain.174,365 As a consequence quality of life can be greatly affected.271,276 
To decrease the rate of missed injuries the concept of a tertiary trauma survey has been proposed for multiple injured patients.33,104,154,264,331 In this approach, repeated physical evaluations and reevaluation of radiographic imaging are essential to improve diagnostic accuracy and completeness, and thus optimize treatment. Indications for surgery are open injuries, soft tissue compromise (e.g., incarceration), neurovascular injury, acute compartment syndrome, and joint dislocations.276 Initial treatment, which, if mandatory, can even be performed in the Emergency Department or Intensive Care Unit as an emergency procedure, includes irrigation and debridement, decompression, reduction, temporary fixation (e.g., K-wire), and/or adjunct external fixator application. The adjunct external fixator facilitates wound care and stabilizes the bony architecture until definite care can be provided. 
Timely soft tissue coverage is required to prevent secondary infection and should usually be combined with definite fracture treatment. Depending on the degree of soft tissue compromise and need for secondary reconstruction the “fix and flap” principle as adapted from lower leg reconstruction119 is recommended. Foot salvage with the goal of functional reconstruction of the foot remains a priority in our hands and requires a damage-control approach in the acute phase and intensive teamwork with plastic surgeons for the secondary reconstruction phase. The indication for acute or delayed minor or even major amputation requires individualized decision making based on injury severity, soft tissue loss, and neurovascular compromise. Important factors that should affect the decision making regarding salvage over amputation include personalized functional prognosis, individualized functional outcome, treatment-dependent risks, and projected costs.269 However, the treatment algorithm should always comply with the principle of “Life Before Limb,” and options need to be reevaluated at the different stages of surgical treatment. Complex reconstruction or salvage procedures that put the patient’s survival at risk are beyond tolerable limits and do not comply with our modern understanding of preservation of a functional extremity. The damage control-guided treatment decision should therefore always be guided by “quoad vitam.” Zwipp et al.365 proposed liberal salvage of the multiple injured foot with a staged approach including revision surgery at 24–48 hours. However, the optimal timeframe of a second look procedure has not been defined by the current literature.359 Early soft tissue coverage within the first week however has been reported to lead to improved outcomes.116,119,188 In contrast, Myerson and colleagues246 reported the failure of early wound coverage after aggressive debridement. 
Jupiter et al.166 showed in an investigational study that factors associated with lower extremity amputation in foot and ankle trauma differ slightly from those in other multitrauma patients. Male gender, blunt trauma, the presence of an associated fracture, and the occurrence of a crush injury or open wound were identified as statistically and clinically significant risk factors. Others have provided evidence that long-term outcome after severe foot injuries is determined by the degrees of soft tissue trauma, hindfoot involvement, and joint reconstruction.174 As an alternative to amputation in the rare circumstance of bilateral traumatic amputations, cross over replantation has been reported as an option.62 

Classification

When evaluating an acutely injured foot a determination of when and to what extent it has been injured facilitates not only the decision making with regards to salvage but also to give a prognosis for survival and outcome. Zwipp et al.365 proposed a grading system for the multiply injured foot comprised of the level of osseous damage and the degree of soft tissue compromise. Five anatomic and functional levels are distinguished and each is assigned one point if involved. The ascending degree of open or closed soft tissue compromise is graded and achieves a maximum score of four points in the case of a degloving injury, subtotal amputation, or “the crushed foot.” If the sum of all involved levels of the foot and the maximum score of soft tissue compromise is equal or above 5 “complex trauma of the foot” is the diagnosis (Fig. 62-50). 
Figure 62-50
 
Schematic of the five functional levels of the foot characterizing a “complex trauma of the foot” according to Zwipp et al.365
Schematic of the five functional levels of the foot characterizing a “complex trauma of the foot” according to Zwipp et al.365
View Original | Slide (.ppt)
Figure 62-50
Schematic of the five functional levels of the foot characterizing a “complex trauma of the foot” according to Zwipp et al.365
Schematic of the five functional levels of the foot characterizing a “complex trauma of the foot” according to Zwipp et al.365
View Original | Slide (.ppt)
X
Zwipp’s scale has been felt to be an important tool to describe injury severity in the adult and pediatric97 population, however, in a recent study it was shown to have no prognostic value.174 Those authors concluded that the scale is not applicable for decision making if amputation is necessary. Also, other scales such as the Hannover Polytrauma Scale and Mangled Extremity Severity Scale were not applicable to characterize complex trauma of the foot and facilitate decision making, as these scores were constructed for the leg rather than for the foot.43 
There have been several efforts to develop classifications of soft tissue injury of the extremities to better understand injury pattern and severity, guide the surgeon through different treatment options, and provide a reasonable prognosis. Myerson246 and coworkers described various types of foot injuries based on the degree of soft tissue compromise, thus, providing a more descriptive classification. Hildago and Shaw144 classified foot injuries with soft tissue involvement based on the degree of soft tissue loss in conjunction with osseous compromise. Type I injuries were determined by soft tissue loss of less than 3 cm2 without osseous injury. Type II injuries had soft tissue loss exceeding 3 cm2 without bony injury, and in type III injuries there was involvement of the osseous scaffold. For the complex type III injuries a staged approach was proposed comprised of soft tissues debridement, osseous reduction and fixation, and secondary flap coverage. Jeng et al.157,158 proposed a classification system and treatment algorithm for plantar skin avulsions (Fig. 62-51). They distinguished between subfascial avulsions (extension deep into the plantar aponeurosis) and suprafascial avulsions. The latter were treated with defatting and full-thickness skin grafting. The subfascial type injuries were further subdivided into avulsions with proximally based vascularized flaps which could be treated by suturing them back into anatomic position, and avulsions with distally based flaps (often devascularized). The authors recommended primary revascularization of these flaps when possible. However, often flap failure was observed requiring secondary reconstruction with free muscle flaps or distally based sural island flaps. 
Figure 62-51
Classification and treatment algorithm for plantar avulsion injuries of the foot according to Jeng et al.157
Rockwood-ch062-image051.png
View Original | Slide (.ppt)
X
The most severe and complex injuries of the lower extremity and foot are mutilating or mangled injuries where the degree of soft tissue compromise and associated bony destruction exceeds the current possibilities of soft tissue and osseous reconstruction. These injuries are discussed in detail in Chapter 16

Bony and Soft Tissue Reconstruction

With high-energy injuries of the foot a wide variety of fractures, fracture–dislocations, and ligamentous disruption, (and thus, osseo-ligamentous instability) can occur. Often combined lesions are identified including a variable number of associated injuries within different areas of the osseous complex. Standardized plain radiographs with AP, lateral, and oblique projections are the basic diagnostic tools used to identify and understand the fracture morphology and injury mechanism. Before definite surgical care high-resolution CT imaging of the foot with coronal, sagittal, and axial reconstruction views has become the standard of care in evaluating and treating high-energy injuries of the foot.174 As a determinant of functional outcome, joint involvement requires thoughtful evaluation. Dynamic evaluation using fluoroscopy under anesthesia is essential to identify both ligamentous and osseous instability. 
Management of bony stability is often difficult in these patients because of the extent of injury to the foot as well as other areas.96 In general, treatment of the multiple injured foot follows closely the suggested treatment of each individual injury. The primary objective is to preserve vascularity, sensory innervations, articular congruity, and three-dimensional architecture. Usually minimally invasive techniques are used to achieve proper reduction. Preserving motion within essential joints is desirable; however, if these joints are unstable temporary transfixation can be achieved using 1.6- or 2.0-mm K-wires crossing the subtalar, talo-navicular, calcaneo-cuboidal, medial and lateral TMT, and even the metatarso-phalangeal joints. Usually, complex trauma of the foot is treated as an emergency including the initial thorough debridement of open wounds combined with gross anatomic reduction and primary stable fixation. Grade I and II open fractures require irrigation and debridement, and, if stable after reduction, minimal invasive fixation using 1.6- or 2.0-mm K-wires. As an alternative 2.7-mm screws can be introduced percutaneously to provide rigid fixation when acceptable fracture reduction and joint reconstruction have been achieved. In the case of Grade III open fractures, following debridement closed reduction and K-wire fixation are performed, in conjunction with additional tibio-calcaneo-metatarsal, tibio-metatarsal, or calcaneo-metatarsal external transfixation. Tibio-calcaneal-metatarsal fixation provides the highest stability in all three planes of the foot (Fig. 62-52). 
Figure 62-52
External fixator application in a 64-year-old man with a grade 3 open calcaneal fracture after a fall from height.
 
An ankle transfixing tibio-calcaneo-metatarsal external fixator was chose to obtain traction along the tibial and calcaneal axis, respectively. A unilateral calcaneal Schanz pin was used to leave the lateral calcaneal aspect uninjured for later operative reconstruction via a lateral approach. A: Medial view. B: Frontal view. C: Lateral view.
An ankle transfixing tibio-calcaneo-metatarsal external fixator was chose to obtain traction along the tibial and calcaneal axis, respectively. A unilateral calcaneal Schanz pin was used to leave the lateral calcaneal aspect uninjured for later operative reconstruction via a lateral approach. A: Medial view. B: Frontal view. C: Lateral view.
View Original | Slide (.ppt)
Figure 62-52
External fixator application in a 64-year-old man with a grade 3 open calcaneal fracture after a fall from height.
An ankle transfixing tibio-calcaneo-metatarsal external fixator was chose to obtain traction along the tibial and calcaneal axis, respectively. A unilateral calcaneal Schanz pin was used to leave the lateral calcaneal aspect uninjured for later operative reconstruction via a lateral approach. A: Medial view. B: Frontal view. C: Lateral view.
An ankle transfixing tibio-calcaneo-metatarsal external fixator was chose to obtain traction along the tibial and calcaneal axis, respectively. A unilateral calcaneal Schanz pin was used to leave the lateral calcaneal aspect uninjured for later operative reconstruction via a lateral approach. A: Medial view. B: Frontal view. C: Lateral view.
View Original | Slide (.ppt)
X
Bony stability facilitates soft tissue healing.96 As an adjunct to percutaneous reduction and fixation, the external fixator provides stability for the soft tissue envelope and bones, and transfixed joints, and it also prevents secondary deformity (equinus contracture), and facilitates soft tissue management for the physician and nursing team on the ward.365 The Schanz pins are placed bicortically using AO technique in the distal diaphyseal tibia, the bases of the first and fifth metatarsals, and the calcaneus. Hence, tibio-calcaneal-metatarsal transfixation allows for axial and sagittal distraction within the forefoot, midfoot, and hindfoot. However, some authors recommend external fixation without involvement of the calcaneus.365 Distraction can be exerted over transfixed joints and anatomic length can be reestablished. The metatarsal fixation allows for neutral positioning of the forefoot to correct supination, pronation, and equinus deformity. If length and articular congruity cannot be restored fully during the acute injury phase using minimally invasive techniques, definitive fixation should be postponed to a later phase of reconstruction. The extremity requires strict elevation and bed rest for at least two to three days. In most cases definite care is delayed until the end of the first week when final debridement is followed by definite open reduction and internal fixation and soft tissue closure. Due to the complex nature of the injury, definite fracture care is performed in a hindfoot-to-forefoot direction. Zwipp et al.365 proposed a strict proximal-to-distal staging of fracture care comprising the following sequence: Talus > Ankle/Pilon > Calcaneus > Chopart > Lisfranc > metatarsals. 
With large osseous defects bone grafting may be necessary. Autograft, allograft, and bone substitutes are options. Some authors have reported lower bone graft survival rates in foot injuries compared to tibial defects;57 therefore, the use of grafts in foot reconstruction of large osseous defects is still under debate. 
Soft tissue defect coverage usually is achieved with local or free tissue transfer. Timing of soft tissue reconstruction depends on the full demarcation of nonviable tissue. During the acute phase within the first 48 hours, a second look procedure is recommended to identify secondary necrotic tissue and debride and irrigate the area of compromise. To prevent skin retraction during the initial phase of tissue consolidation elastic skin traction138,155,203,353 can be used to provide dynamic wound size reduction. Most recently Kakagia et al.168 provided evidence that this technique is a safe, reliable, and cost-efficient tool for gradual mechanical dermal apposition when compared to vacuum-assisted closure. 
In most cases definite flap coverage can be achieved within 5 days after complex foot trauma.46 Postoperative care is based on the individual injuries present and the treatment given. 
In complex foot injuries, the soft tissues have to be evaluated carefully to exclude a compartment syndrome and or ischemia of the foot. All open wounds should be thoroughly debrided on the day of presentation. Bhandari et al.30 showed in an in vitro model that early debridement with low-pressure lavage is more effective and safer at removing bacteria than delayed debridement and high-pressure lavage. Aggressive debridement often results in an increased size of the soft tissue defects that cannot be covered with local flaps.57 Furthermore, the involvement of local muscles and their vascular pedicles often limits their usefulness as local muscular flaps. Regardless, surgical debridement should be complete and include all contaminated and necrotic tissue. The type of soft tissue coverage has a significant impact on the healing response of an underlying fracture and some authors have shown good results with liberal use of muscular flap coverage.57 The timing of coverage of soft tissue defects remains a topic of debate, however, distinct phases for tissue transfer for complex foot trauma have been defined discriminating acute care (0 to 24 hours), urgent revision (within 24 to 72 hours), early revision (72 to 100 hours), and delayed revision (more than 120 h).46 Lowered infection rates and satisfactory 1-year results have been seen after early soft tissue coverage for complex foot trauma.46 Recently, Liu et al.188 provided evidence that early soft tissue reconstruction (within 1 to 3 days) and shortened hardware exposure (<7 days) was associated with lower rates of preflap wound infection. Myerson and colleagues246 reported good results after immediate wound coverage using split-thickness skin grafting in patients sustaining shear-type degloving injuries of the foot. In contrast, use of skin grafts or fasciocutaneous flaps in traumatic leg wounds has been reported to be associated with higher rates of failure and complications.57 
In some cases, local flaps and free tissue transfers have been reported to lead to good results.46 To obtain primary closure, muscle flaps usually require immediate split-thickness skin grafting. A gracilis muscle flap has been recommended for small defects.57 However, the relatively short vascular pedicle of this flap has been recognized as a disadvantage; therefore, in some cases a serratus muscle flap should be considered as an alternative (Tables 62-19 and 62-20). 
Table 62-19
Key Points in the Management of High-Energy Injuries of the Foot According to Celiköz et al57
Evaluation by an experienced team
Active involvement of patient in decision-making process
Consideration of functional success rather than technical success
Constant reassessment of salvage vs. primary amputation
Effective bone stabilization (external fixator + K-wire transfixation)
Early, aggressive, and serial debridements of osseous and soft tissue
Early simultaneous osseous and soft tissue reconstruction
Liberal use of free muscle flaps, fibula flaps, and bone grafts
Early and intensive rehabilitation
Gradual and guarded weight bearing
Patient education
X
 
Table 62-20
Flap Coverage Options
View Large
Table 62-20
Flap Coverage Options
Complex Trauma of the Foot
Local Flap Free Flap
Distally based sural artery neurocutaneous Fasciocutaneous radial forearm
Extensor digitorum brevis muscle Lateral forearm
Flexor digitorum brevis muscle Latissimus dorsi
Medial plantar (instep) Rectus abdominis muscle
Dorsalis pedis island pedicle Serratus anterior muscle
Fasciocutaneous island Gracilis muscle
Lateral calcaneal
Abductor digiti minimi muscle
X

Compartment Syndrome of the Foot

The acute compartment syndrome of the foot is recognized as an absolute emergency in the treatment of foot and ankle trauma and requires immediate surgical intervention. Willful ignorance or simple overlooking of this complicating condition during the treatment of acute foot and ankle trauma should be rare since the compartment syndrome has drawn increasing interest with respect to experimental and clinical evaluation within the orthopedic trauma community. Typically, an acute compartment syndrome results from high-energy injuries affecting the integrity of the bones and soft tissues.108,198,224,241,324,363 Delay or even failed treatment will lead to significant loss of function of the affected extremity.100,198,240 High-energy injuries such as the multiple injured, the overrun, or the crushed foot,108,3362 respectively, but also midfoot injuries,108 such as a TMT fracture–dislocation, and calcaneal fractures241,319 have been associated with a compartment syndrome of the foot. In general intractable pain, sensory deficit, and progressive pain on muscle stretching are typical findings leading to the diagnosis of an acute compartment syndrome of the foot. Clinical findings require precise documentation to justify further observation or the need for a surgical intervention. A thoughtful clinical exam with a high index of suspicion is required to detect a compartment syndrome after foot and ankle trauma. However, typical signs can be obscured by the degree of trauma-related pain and functional impairment and are therefore often not reliable. The most sensitive diagnostic tool is an intracompartmental pressure measurement within the major foot compartments. Especially the calcaneal compartment needs to be assessed properly. A fasciotomy is required if the difference between the diastolic blood pressure and the compartment pressure is less than 30 mm Hg. Immediate fasciotomy of all affected compartments has been recognized as the standard of care and is typically performed via a dorso-medial, dorso-lateral, and a medial approach.286 However, despite proper surgical intervention, nerve and muscle dysfunction are common sequelae.198,246 Secondary deformity, impaired motion, and sensory neuropathy are also common complications.198,246,324 

Anatomic and Pathophysiologic Considerations

Sarrafian and Kelikian300 showed that the superficial aponeurosis of the distal leg continues on to the dorsum of the foot, and hence, the anterior compartment is continued distally into the foot as its dorsal compartment.24 The two deep posterior compartments of the distal leg are in continuity with the plantar compartments of the foot via the four fibrous tunnels ensheathing the tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus, as well as the posterior neurovascular bundle.300 Furthermore, the peroneal compartment communicates with the plantar foot via the fibrous tunnel of the peroneus longus tendon. These anatomical characteristics account for the coincidental occurrence of acute compartment syndromes in the distal leg and foot.99,198 
Historically the plantar aspect of the foot has been divided into four major compartments: medial/tibial, lateral/peroneal, central, and interosseous.300,358 The medial compartment is confined by the plantar aponeurosis and the medial intermuscular septum, has no direct communication with the calcaneal tunnel or the central compartment, and is located plantar and medial to the first metatarsal.300 The lateral compartment, which, similarly to the medial plantar compartment does not communicate with the calcaneal tunnel or central compartment, is formed by the insertion of the lateral segment of the plantar aponeurosis and the lateral intermuscular septum.300 It is located on the infero-lateral aspect of the fifth metatarsal. The central compartment is characterized by three subunits. The superficial central compartment has been recognized as independent, and not communicating with the surrounding compartments.201 The intermediate central compartment is located dorsal to the superficial subunit and communicates proximally with the inferior calcaneal tunnel and indirectly via the tibio-talo-calcaneal tunnel with the posterior compartment of the distal leg.300 The deep central compartimental subunit is seen only in the forefoot and comprises the oblique head of the adductor hallucis muscle.300 The interosseous plantar compartment is divided into four spaces comprising the corresponding plantar and dorsal interosseous muscles. It is defined plantarly by the interosseous fascia, which has been characterized as the upper limb of an horizontally oriented y-shaped septum,169 extending from the first to the fifth metatarsal. Dorsally the interosseous compartment is limited by the dorsal interosseous aponeurosis and is further subdivided into four separate spaces by vertical fascial septae300 (Fig. 62-53). 
Figure 62-53
MR images of the foot delineating the different compartments of the foot.
 
A: Coronal view at the Chopart joint line (Nav, tarsal navicular bone; Cub, cuboid bone; 1, medial compartment = M. abductor hallucis; 2, deep central compartment = M. quadrates plantae; 3, superficial plantar compartment = M. flexor digitorum brevis; 4, lateral compartment = M. abductor digiti minimi; 5, M. extensor digiti brevis). B: Coronal view at the bases of the metatarsals (MT 1–5: Metatarsals 1 to 5. 1, M. abductor hallucis; 2, M. flexor hallucis brevis; 3, M. adductor hallucis, oblique head; 4, tendons of M. flexor digitorum longus and brevis, and Mm. lumbricales; 5, Mm interossei plantaris 4 and 5; 6, M. abductor digiti minimi).
A: Coronal view at the Chopart joint line (Nav, tarsal navicular bone; Cub, cuboid bone; 1, medial compartment = M. abductor hallucis; 2, deep central compartment = M. quadrates plantae; 3, superficial plantar compartment = M. flexor digitorum brevis; 4, lateral compartment = M. abductor digiti minimi; 5, M. extensor digiti brevis). B: Coronal view at the bases of the metatarsals (MT 1–5: Metatarsals 1 to 5. 1, M. abductor hallucis; 2, M. flexor hallucis brevis; 3, M. adductor hallucis, oblique head; 4, tendons of M. flexor digitorum longus and brevis, and Mm. lumbricales; 5, Mm interossei plantaris 4 and 5; 6, M. abductor digiti minimi).
View Original | Slide (.ppt)
Figure 62-53
MR images of the foot delineating the different compartments of the foot.
A: Coronal view at the Chopart joint line (Nav, tarsal navicular bone; Cub, cuboid bone; 1, medial compartment = M. abductor hallucis; 2, deep central compartment = M. quadrates plantae; 3, superficial plantar compartment = M. flexor digitorum brevis; 4, lateral compartment = M. abductor digiti minimi; 5, M. extensor digiti brevis). B: Coronal view at the bases of the metatarsals (MT 1–5: Metatarsals 1 to 5. 1, M. abductor hallucis; 2, M. flexor hallucis brevis; 3, M. adductor hallucis, oblique head; 4, tendons of M. flexor digitorum longus and brevis, and Mm. lumbricales; 5, Mm interossei plantaris 4 and 5; 6, M. abductor digiti minimi).
A: Coronal view at the Chopart joint line (Nav, tarsal navicular bone; Cub, cuboid bone; 1, medial compartment = M. abductor hallucis; 2, deep central compartment = M. quadrates plantae; 3, superficial plantar compartment = M. flexor digitorum brevis; 4, lateral compartment = M. abductor digiti minimi; 5, M. extensor digiti brevis). B: Coronal view at the bases of the metatarsals (MT 1–5: Metatarsals 1 to 5. 1, M. abductor hallucis; 2, M. flexor hallucis brevis; 3, M. adductor hallucis, oblique head; 4, tendons of M. flexor digitorum longus and brevis, and Mm. lumbricales; 5, Mm interossei plantaris 4 and 5; 6, M. abductor digiti minimi).
View Original | Slide (.ppt)
X
Based on current experimental work nine separate compartments can be distinguished within the foot,201 and recently, 10 compartments have been described using MR imaging technique;283,284 however, the clinical relevance of the additional compartments could not be shown. The muscular content and neurovascular structures at risk within each compartmental unit are delineated in Table 62-21
 
Table 62-21
Compartments of the Foot
View Large
Table 62-21
Compartments of the Foot
Compartment Muscle/Tendon Structures at Risk Dimension/Characteristics
Dorsal (Skin) M. extensor digitorum brevis
M. extensor hallucis brevis
M. extensor digitorum longus tendons
Nn cutaneous dorsalis lateralis/intermedius/medius
A. dorsalis pedis/dorsales metatarsals/plantaris profundus
Not osseofascial
Communicates with anterior compartment of the distal leg
Landmark: Prominent swelling
Needle position: Dorsum/plantar heel
Distance: N/A
Depth: 0.8 mm dorsal/10 mm plantar
Medial M. abductor hallucis
M. flexor hallucis brevis
M. flexor hallucis longus tendons
A./N. plantaris medialis superf. Isolated closed space
Landmark: Medial malleolus
Distance: ∼6 cm
Depth: ∼11 mm
Lateral M. abductor digiti minimi
M. flexor digitorum minimi brevis
M. opponens digiti minimi
A./N. plantaris lateralis superf. Isolated closed space
Landmark: Lateral malleolus
Distance: ∼11 cm
Depth: ∼11 mm
Central Superficial M. flexor digitorum brevis
Mm. lumbricales
M. flexor digitorum longus tendons
Aa./Nn. plantares digitorum communes
N. plantaris medialis
Isolated closed space
Landmark: Plantar fat pad insertion
Distance: ∼11.5 cm
Depth: ∼10 mm
Deep
(adductor)
M. adductor hallucis, oblique head Relatively isolated closed space
Landmark: Plantar fat pad insertion
Distance: ∼11.5 cm
Depth: ∼21 mm
Intermediate (calcaneal) M. quadratus plantae
M. flexor digitorum longus/lumbricales, proximal segment
A. plantaris lateralis
N. plantaris medialis and lateralis
N. abductor digitorum min.
Communicates with posterior compartment of the distal leg (via tibio-talo-calcaneal tunnel)
Landmark: Medial malleolus
Distance: ∼6 cm
Depth: ∼24 mm
Interosseous MT 1/2
MT 2/3
MT 3/4
MT 4/5
Corresponding plantar/dorsal Mm. interossei A. plantaris profundus
A. metatarsalis plantaris
Arcus plantaris profundus
A. plantaris lateralis
Each isolated closed space
Landmark: Medial malleolus
Needle position: Interosseous space
Distance: ∼13–15 cm
Depth: ∼10–12 mm
X
A compartment syndrome is defined as an increase of the intramuscular pressure within an osseo-fascial compartment which decreases local vascular perfusion, exceeding the level at which diminished perfusion results in ischemia of the muscles within that compartment. The first reports date back to the beginning of the 19th century when Volkmann reported the symptom complex today known as the compartment syndrome, stating that: “…as assumed by then, the paralysis and contractures of the limbs observed after constricting dressings, are not a result from pressure induced palsy of the nerve, but rapid and progressive accumulation of large quantities of break-up of the contractile substance and following reactive and regenerative processes”.344 The excessive rise of the pressure within a musculo- or osseo-fascial compartment leads to disturbance of the neuromuscular function. External compression, as well as intra-compartmental swelling interferes with capillary perfusion. The latter can also be accompanied by interstitial or intracellular edema. Accepted pathophysiologic mechanisms include capillary collapse, venous obstruction, arterial spasm, and muscular exertion.18,25,37,64,99,184 An increase in intra-compartmental fluid volume results in a progressive rise in the pressure within the stiff fascial sheath. Furthermore, pressure-induced ischemia results in altered capillary perfusion, acute inflammation, and cellular apoptosis and necrosis due to a state of low-flow ischemia.184 Hence, pressure-induced ischemia and an ischemia-related increase in intra-compartmental volume can result a vicious cycle. Normal musculo-fascial compartment pressure usually is below 8 mm Hg.44 Compartment pressures above 30 mm Hg applied over ischemia-sensitive time intervals have been shown to be related to time- and pressure-dependent neuro-muscular tissue dysfunction.115 Hargens and coworkers136 provided evidence that after 8 hours of compartmental pressure equal to or above 30 mm Hg significant muscular necrosis is induced. In the foot, cadaver studies have shown that with intact skin, a pressure increase in one osseo-fascial space results in concurrent pressure increase in all other compartments of the foot.286 Furthermore, Myerson242 observed volumetric shifting between compartmental units of the foot when pressures increased above 50 mm Hg. 

Diagnosis

To date invasive measurement of intramuscular pressure is the most reliable tool for the accurate diagnosis of an acute compartment syndrome,228,242,286,350 and it can be considered as the gold standard. In contrast, clinical signs show a low sensitivity of 13% to 19% in the detection of an acute compartment syndrome of the leg.338 Similarly, a low sensitivity can be assumed for the clinical diagnosis of acute compartment syndromes of the foot. However, common clinical findings are swelling and tension over accessible compartments, intractable or excessive pain, exacerbation of pain by passive muscular stretch, and sensory or muscular dysfunction.44,100,108,198,241,254 Noninvasive techniques include quantitative external measurement of compartment hardness,87 peripheral pulse oximetry,203 MRI imaging,10 ultrasonic fascial displacement,192,351 and near infrared spectroscopy.341 However, noninvasive techniques lack sufficient evidence and therefore require further investigation. 
In the case of clinical suspicion, invasive pressure measurements should be performed to identify or rule out an acute compartment syndrome. Typical reading sites are determined by the anatomical rational of compartmental expansion as shown by recent analyses (Fig. 62-54).241,283,284,286 
Figure 62-54
Acute compartment syndrome of the foot in a 64-year-old man who sustained a grade 3 open calcaneal fracture after a fall from height.
 
An ankle transfixing tibio-calcaneo-metatarsal external fixator was applied after irrigation and debridement of the medial wound. A: Before closed reduction, intraoperative invasive compartment pressure measurement at the calcaneal plantar compartment. B: After closed reduction and external tibio-calcaneal-metatarsal external fixator application (measure sites: yellow, lateral plantar compartment; red, calcaneal plantar compartment; black, plantar central abductor compartment; blue, medial plantar compartment). C: Compartment pressure measurement of the dorsal intermetatarsal compartments.
An ankle transfixing tibio-calcaneo-metatarsal external fixator was applied after irrigation and debridement of the medial wound. A: Before closed reduction, intraoperative invasive compartment pressure measurement at the calcaneal plantar compartment. B: After closed reduction and external tibio-calcaneal-metatarsal external fixator application (measure sites: yellow, lateral plantar compartment; red, calcaneal plantar compartment; black, plantar central abductor compartment; blue, medial plantar compartment). C: Compartment pressure measurement of the dorsal intermetatarsal compartments.
View Original | Slide (.ppt)
Figure 62-54
Acute compartment syndrome of the foot in a 64-year-old man who sustained a grade 3 open calcaneal fracture after a fall from height.
An ankle transfixing tibio-calcaneo-metatarsal external fixator was applied after irrigation and debridement of the medial wound. A: Before closed reduction, intraoperative invasive compartment pressure measurement at the calcaneal plantar compartment. B: After closed reduction and external tibio-calcaneal-metatarsal external fixator application (measure sites: yellow, lateral plantar compartment; red, calcaneal plantar compartment; black, plantar central abductor compartment; blue, medial plantar compartment). C: Compartment pressure measurement of the dorsal intermetatarsal compartments.
An ankle transfixing tibio-calcaneo-metatarsal external fixator was applied after irrigation and debridement of the medial wound. A: Before closed reduction, intraoperative invasive compartment pressure measurement at the calcaneal plantar compartment. B: After closed reduction and external tibio-calcaneal-metatarsal external fixator application (measure sites: yellow, lateral plantar compartment; red, calcaneal plantar compartment; black, plantar central abductor compartment; blue, medial plantar compartment). C: Compartment pressure measurement of the dorsal intermetatarsal compartments.
View Original | Slide (.ppt)
X
Reach and coworkers169 have provided evidence for optimal needle positioning based on MR imaging findings. Based on those findings the medial compartment can be accessed by introducing a needle approximately 6 cm plantar to the most prominent point of the medial malleolus at a depth of approximately 11 mm. Similar findings have been reported by others.110 By introducing the needle to a total depth of approximately 2.4 cm the calcaneal compartment (which has been identified as the most sensitive197) is accessed. For lateral compartment pressure readings a needle is placed approximately 11 mm deep at a point 11 cm distal on a line between the most prominent aspect of the lateral malleolus and fifth metatarsal head. The central superficial compartment is reached approximately 11 cm from the plantar fat pad insertion along the midline distally at a depth of 1 cm. Advancing the needle to 2 cm accesses the deep central or adductor compartment (Fig. 62-55). 
Figure 62-55
Illustration of the plantar compartments of the foot modified from Wülker.360
 
1: Medial compartment. 2: Lateral compartment. 3: Superficial central compartment. 4: Deep (adductor) central compartment. 5: Intermediate (calcaneal) central compartment. 6: Interosseous compartment.
1: Medial compartment. 2: Lateral compartment. 3: Superficial central compartment. 4: Deep (adductor) central compartment. 5: Intermediate (calcaneal) central compartment. 6: Interosseous compartment.
View Original | Slide (.ppt)
Figure 62-55
Illustration of the plantar compartments of the foot modified from Wülker.360
1: Medial compartment. 2: Lateral compartment. 3: Superficial central compartment. 4: Deep (adductor) central compartment. 5: Intermediate (calcaneal) central compartment. 6: Interosseous compartment.
1: Medial compartment. 2: Lateral compartment. 3: Superficial central compartment. 4: Deep (adductor) central compartment. 5: Intermediate (calcaneal) central compartment. 6: Interosseous compartment.
View Original | Slide (.ppt)
X
The interosseous compartments are reached by positioning the needle dorsally between the respective metatarsals at a depth of 1 cm and varying distance distally from the medial malleolus from 13 cm (MT 1/2) to 15 cm (MT 4/5), respectively. 
Periodic reevaluation is recommended to identify the development of a delayed compartment syndrome due to secondary swelling and the vicious nature of the ischemia- and volume-dependent pathophysiology. Special concern should be taken in the unconscious patient and those sustaining severe or multiple injuries to the foot. 

Treatment

Operative treatment for a compartment syndrome of the foot has been reported after crush injuries,278,287,362 calcaneal fractures,226,241,319,347 midfoot injuries (especially Chopart or Lisfranc fracture–dislocations),108,197,330 and other foot and ankle trauma,23,29,85,100,108,125,140,174,183 but also after excessive sports and exertion14,21,34,35,219,223 or as a sequelae of reperfusion-injury.17 Acute compartment syndromes in children are rare.31,97,210,316 Also, chronic compartment syndromes of the foot have been reported.164,189 
The exact incidence and the predisposing factors for the development of a compartment syndrome of the foot remain uncertain. Recently, Thakur and coworkers329 provided evidence, based on an analysis of patients with an isolated foot injury from a National Trauma Data Bank, that the overall incidence of patients requiring fasciotomy for a presumed compartment syndrome of the foot was 2% with a predominance of white males in their mid-thirties. A crush injury mechanism has been identified as the most important factor in the development of a compartment syndrome of the foot; it nearly doubled the relative risk. Interestingly, an increase in the number of anatomic locations was not related to a higher incidence of compartment syndromes of the foot. Furthermore, isolated injuries of the forefoot accounted for almost one-third of the compartment syndromes and combined injuries of the forefoot and midfoot were identified as a risk factor. Contrary to previous reports, that a calcaneal fracture would be complicated in up to 10% by the development of a compartment syndrome,241 Thakur and coworkers329 identified a prevalence of 1% within the cohort of isolated hindfoot injuries including calcaneal fractures. As there is communication between the compartments of the foot and the distal leg, concurrent occurrence of compartments syndromes within both areas of the lower extremity108,198 should be kept in mind. 
Splitting and spreading an encircling cast can significantly reduce compartment pressures.114 Thus, taking down any compressive bandage or cast should be the primary treatment followed by close reevaluation using clinical and invasive methods. Furthermore, elevation of the lower extremity has been shown to significantly reduce pressures within the compartments of the distal leg.352,354 
The indications for operative treatment are presented in (Table 62-22). If the diagnosis of an acute compartment syndrome of the foot has been substantiated, immediate release of the compartments of the foot is required. Surgical treatment by open fasciotomy to release elevated compartment pressures was first reported by Bardenheuer.22 To date, the three-incision approach remains the most reliable way to decompress all nine or ten compartments including the deep calcaneal (Fig. 62-56).96 In a cadaver compartment model it was shown that a fasciotomy in one area influenced pressures in all other spaces of the foot. The quickest and most effective pressure reduction for all foot compartments, including the tarsal tunnel, was recorded using a medial midfoot incision.286 Neither a single nor a double dorsal fasciotomy achieved the short-term effects seen with a medial approach.286 Also other authors have reported the most effective pressure decrease is achieved using a medial approach.242 
 
Table 62-22
Acute Compartment Syndrome
View Large
Table 62-22
Acute Compartment Syndrome
Surgical Treatment
Indications
Clinical suspicion (intractable pain, exacerbation of pain on muscular stretch)
Invasive pressure measurement:
>30 mm Hg
<30 mm Hg below diastolic blood pressure
<30–40 mm Hg below mean arterial pressure
The “crushed foot”
The “multiply injured foot”
X
Figure 62-56
Recommended method of foot fasciotomy.
 
A: Relative incision locations on the foot surface. B: Path of blunt dissection through the dorsum of the forefoot. C: The position and direction of the medial incision to reach the calcaneal and oblique adductor hallucis compartments.
A: Relative incision locations on the foot surface. B: Path of blunt dissection through the dorsum of the forefoot. C: The position and direction of the medial incision to reach the calcaneal and oblique adductor hallucis compartments.
View Original | Slide (.ppt)
Figure 62-56
Recommended method of foot fasciotomy.
A: Relative incision locations on the foot surface. B: Path of blunt dissection through the dorsum of the forefoot. C: The position and direction of the medial incision to reach the calcaneal and oblique adductor hallucis compartments.
A: Relative incision locations on the foot surface. B: Path of blunt dissection through the dorsum of the forefoot. C: The position and direction of the medial incision to reach the calcaneal and oblique adductor hallucis compartments.
View Original | Slide (.ppt)
X
As outlined for the surgical exposure of the TMT complex the most common surgical approach is a dorsal-medial longitudinal incision in the web space between the first and second metatarsals (mid-diaphyseal). The incision continues proximally in the interval between the first and second TMT joints and, if required, it can be extended to the body of the navicular or talus. The tendons of the extensor hallucis longus and extensor digitorum brevis are identified and retracted laterally or medially depending on the intermetatarsal interval that will be addressed. A full-thickness fasciocutaneous flap is created to protect the neurovascular bundle. To address the lateral interosseous compartments a second surgical incision is recommended. Leaving a skin bridge of at least 3 cm is mandatory to prevent secondary skin necrosis. However, optimal skin bridge dimensions have not been defined in the current literature. The dorso-lateral incision is placed over the fourth metatarsal extending proximally to the cuboid bone. Starting from that incision the surgeon will be able to address the dorsal compartment containing the extensor hallucis and digitorum brevis muscles, the lateral two interosseous compartments (intermetatarsal spaces 3/4 and 4/5), the lateral TMT joint complex, and the cuboid bone. The lateral cutaneous branch of the peroneal nerve should be identified and protected. Blunt dissection between the interosseous muscles and the fascia allows access to the deep central (adductor) compartment via the intermetatarsal space. The lateral compartment is reached by releasing the fascia attached to the infero-lateral aspect of the fifth metatarsal via the lateral incision. The third, medial incision is used to access the medial and central compartments. The incision lies within the arch of the foot along the muscle body of the abductor hallucis. Dissection is carried both dorsal and plantar to this muscle, freeing it up from the plantar fascia and its attachments to the bony structures dorsally. The medial fascia of the abductor and flexor hallucis brevis muscles is incised, allowing access to the fascia of the flexor digitorum brevis and adductor hallucis muscles (Fig. 62-57). 
Figure 62-57
Schematic of the surgical approach for fasciotomy of all 9 (10) compartments of the foot using a three-incision technique to address an acute compartment syndrome of the foot.
Rockwood-ch062-image057.png
View Original | Slide (.ppt)
X
Medial dissection requires careful preparation due to close proximity of sensitive neurovascular structures. The lateral plantar neurovascular bundle is located on the quadratus muscle and can be seen with the release of the intermediate central compartment. If the medial or lateral column of the foot is shortened or unstable, length and articular congruence should be restored using indirect percutaneous techniques and a temporary external fixator is placed over the columns of the foot, which can be left in place as an adjunct in the postoperative phase. In the presence of a compartment syndrome, the optimal time point for definitive fracture care is still under debate. Due to the significant impact on the soft tissue envelope resulting from the primary injury and the presence of the acute compartment syndrome the impact of a “second hit” from an invasive surgical intervention should be reduced to a minimum. Therefore, minimal-invasive reduction techniques and percutaneous fixation methods seem advisable. 
To prevent secondary skin retraction skin traction should be applied.155 Wounds are inspected on a daily basis and the skin traction can be further tensioned. The wounds should be closed in a secondary fashion at 5 to 7 days after primary treatment. In severe cases, selected amputation may be necessary (Table 62-23). 
 
Table 62-23
Acute Compartment Syndrome of the Foot
View Large
Table 62-23
Acute Compartment Syndrome of the Foot
Surgical Steps
  •  
    Use three-incision technique to access all 9 (10) compartments of the foot
  •  
    Definitive treatment: (if intrinsically stable, and soft tissue compromise low)
    •  
      I and D
    •  
      Apply skin traction
    •  
      Second look @ 12–48 h
    •  
      Wound closure @ 5–7 d (primary closure, skin graft)
  •  
    Staged treatment: (if intrinsically unstable and/or impending soft tissue compromise)
     
    Early phase
    •  
      I and D
    •  
      Temporary fixation (K-wire /2.7mm screw) + adjunct external fixation
    •  
      Apply dermatotraction
    •  
      Second look @ 12–48 h
       
      Reconstructive phase
    •  
      Definitive osseous reconstruction
    •  
      Wound closure @ 5–7 d (primary closure, skin graft, or flap coverage)
  •  
    Reassess for compartment syndrome using intraoperative invasive pressure measurements
    •  
      If still present, reevaluate completeness of fasciotomy of all compartmental units (especially intermediate central compartment)
X

Complications

Complications are common and are determined by the time and completeness of surgical intervention. Incomplete or delayed fasciotomy fails to interrupt the vicious cycle within the compartment and can result in significant morbidity.109,197,200 Templeman and coworkers326 identified failure to consider the diagnosis, inadequate response to nursing staff calls, incomplete examination, failure to perform invasive measurements, and disruption of continuity of care as causes for delayed or failed diagnosis of a compartment syndrome. If missed, compartment syndromes of the foot most often lead to deformity of the toes and axial tarsal malalignment (cavus).329 Cavus deformity results from intrinsic muscle weakness or contracture of the quadratus plantae within the calcaneal compartment or fibrosis of the neuromuscular tissue within the plantar foot or distal leg. Furthermore, the compartment syndrome can be associated with myoneural ischemia leading to significant problems within the foot.246 Paresthesias, claw toe deformity, and impaired motion are common findings.109,197,200,246,324,329 If fixed, toe deformities require surgical release and realignment to alleviate pain and improve shoe fit. Also, the development of hallux varus deformity has been reported.81 Neuroischemia may play a role in the development of chronic pain after crush injuries of the foot.246 Also, secondary scarring of the dorsal soft tissue envelope can cause decreased active and passive motion of the hallux and lesser toes. Finally, the surgical intervention can be complicated by dorsal skin bridge necrosis and neurovascular damage. 

Acknowledgment

We thank Dominik Seybold, MD, PhD for his contribution in structural design, image creation, and processing. Also we would like to thank Ms. Eva Sturm in supporting literature research. 

References

1.
Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. 1998;19(2):91–97.
2.
Adams E, Madden C. Cuboid subluxation: A case study and review of the literature. Curr Sports Med Rep. 2009;8(6):300–307.
3.
Adelaar RS. The treatment of tarsometatarsal fracture-dislocation. Instr Course Lect. 1990;39:141–145.
4.
Adelaar RS. Complications of forefoot and midfoot fractures. Clin Orthop Relat Res. 2001;391:26–32.
5.
Aggarwal PK, Singh S, Kumar S. Isolated dorsal dislocation of the intermediate cunieform: A case report and review of the literature. Arch Orthop Trauma Surg. 2003;123(5):252–253.
6.
Ahmed S, Bolt B, McBryde A. Comparison of standard screw fixation versus suture button fixation in Lisfranc ligament injuries. Foot Ankle Int. 2010;31(10):892–896.
7.
Aitken AP, Poulson D. Dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1963;45-A:246–260.
8.
Aitken SA, Shortt N. Dorsomedial fracture dislocation of the first ray and medial cuneiform: A case report. J Foot Ankle Surg. 2012;51(6):795–797.
9.
Alberta FG, Aronow MS, Barrero M, et al. Ligamentous Lisfranc joint injuries: A biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. 2005;26(6):462–473.
10.
Amendola A, Rorabeck CH, Vellett D, et al. The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med. 1990;18(1):29–34.
11.
Andermahr J, Helling HJ, Maintz D, et al. The injury of the calcaneocuboid ligaments. Foot Ankle Int. 2000;21(5):379–384.
12.
Anderson LD. Injuries of the forefoot. Clin Orthop Relat Res. 1977;122:18–27.
13.
Apostle KL, Younger AS. Technique tip: Open reduction internal fixation of comminuted fractures of the navicular with bridge plating to the medial and middle cuneiforms. Foot Ankle Int. 2008;29(7):739–741.
14.
Arkless R. Re: Acute, exertional medial compartment syndrome of the foot in a high-level athlete: A case report. Am J Sports Med. 2008;36(11):e1; author reply e1.
15.
Armagan OE, Shereff MJ. Injuries to the toes and metatarsals. Orthop Clin North Am. 2001;32(1):1–10.
16.
Arntz CT, Veith RG, Hansen ST Jr. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70(2):173–181.
17.
Ascer E, Strauch B, Calligaro KD, et al. Ankle and foot fasciotomy: An adjunctive technique to optimize limb salvage after revascularization for acute ischemia. J Vasc Surg. 1989;9(4):594–597.
18.
Ashton H. The effect of increased tissue pressure on blood flow. Clin Orthop Relat Res. 1975;113:15–26.
19.
Ashworth MJ, Davies MB, Williamson DM. Irreducible Lisfranc’s injury: The ‘toe up’ sign. Injury. 1997;28(4):321–322.
20.
Astion DJ, Deland JT, Otis JC, et al. Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am. 1997;79(2):241–246.
21.
Baker JF, Lui DF, Kiely PD, et al. Foot drop–an unusual presentation of exertional compartment syndrome. Clin J Sport Med. 2009;19(3):236–237.
22.
Bardenheuer B. Die Entstehung und Behandlung der ischämischen Muskelkontraktur und Gangrän. Dtsch Z Chir. 1911;108:44–201.
23.
Bayer JH, Davies AP, Darrah C, et al. Calcaneal compartment syndrome after tibial fractures. Foot Ankle Int. 2001;22(2):120–122.
24.
Bellocq P, Meyer P. Contribution to the study of the dorsal aponeurosis of the foot (fascia dorsalis pedis, P.N.A.). Acta Anat (Basel). 1957;30(1–4):67–80.
25.
Benjamin A. The relief of traumatic arterial spasm in threatened Volkmann’s ischaemic contracture. J Bone Joint Surg Br. 1957;39-B(4):711–713.
26.
Bennell KL, Malcolm SA, Thomas SA, et al. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211–217.
27.
Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(6):810–818.
28.
Bertoldi L, Molinari M, Soldini A, et al. Isolated fracture-dislocation of the second cuneiform bone. Case report. Acta Orthop Scand. 1991;62(6):604–605.
29.
Besch L, Drost J, Egbers HJ. [Treatment of rare talus dislocation fractures. An analysis of 23 injuries]. Unfallchirurg. 2002;105(7):595–601.
30.
Bhandari M, Schemitsch EH, Adili A, et al. High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage. J Orthop Trauma. 1999;13(8):526–533.
31.
Bibbo C, Lin SS, Cunningham FJ. Acute traumatic compartment syndrome of the foot in children. Pediatr Emerg Care. 2000;16(4):244–248.
32.
Bichara DA, Henn RF 3rd, Theodore GH. Sesamoidectomy for hallux sesamoid fractures. Foot Ankle Int. 2012;33(9):704–706.
33.
Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary trauma survey decreases missed injuries. J Trauma. 2003;54(1):38–43; discussion 43-34.
34.
Bishop GW, Fallon KE. Musculoskeletal injuries in a six-day track race: Ultramarathoner’s ankle. Clin J Sport Med. 1999;9(4):216–220.
35.
Blacklidge DK, Kurek JB, Soto AD, et al. Acute exertional compartment syndrome of the medial foot. J Foot Ankle Surg. 1996;35(1):19–22.
36.
Blair BH. Dislocation of the cuneiform bones. Cincinnati Lancet-Clinic. 1899;43:513.
37.
Blandy JP, Fuller R. March gangrene; ischaemic myositis of the leg muscle from exercise. J Bone Joint Surg Br. 1957;39-B(4):679–693.
38.
Blumberg K, Patterson RJ. The toddler’s cuboid fracture. Radiology 1991;179(1):93–94.
39.
Blundell CM, Nicholson P, Blackney MW. Percutaneous screw fixation for fractures of the sesamoid bones of the hallux. J Bone Joint Surg Br. 2002;84(8):1138–1141.
40.
Bohay DR, Johnson KD, Manoli A 2nd. The traumatic bunion. Foot Ankle Int. 1996;17(7):383–387.
41.
Böhler L. Verrenkungen im Lisfranc’schen Gelenk. Die Technik der Knochenbruchbehandlung. Vol II/2. Wien, Bonn, Bern: Wilhelm Maudrich; 1957:2237–2245.
42.
Boike A, Schnirring-Judge M, McMillin S. Sesamoid disorders of the first metatarsophalangeal joint. Clin Podiatr Med Surg. 2011;28(2):269–285, vii.
43.
Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am. 2001;83-A(1):3–14.
44.
Botte MJ, Santi MD, Prestianni CA, et al. Ischemic contracture of the foot and ankle: Principles of management and prevention. Orthopedics. 1996;19(3):235–244.
45.
Bramble DM, Lieberman DE. Endurance running and the evolution of Homo. Nature. 2004;432(7015):345–352.
46.
Brenner P, Rammelt S, Gavlik JM, et al. Early soft tissue coverage after complex foot trauma. World J Surg. 2001;25(5):603–609.
47.
Brown DC, McFarland GB Jr. Dislocation of the medial cuneiform bone in tarsometatarsal fracture-dislocation. A case report. J Bone Joint Surg Am. 1975;57(6):858–859.
48.
Brukner P, Bradshaw C, Khan KM, et al. Stress fractures: A review of 180 cases. Clin J Sport Med. 1996;6(2):85–89.
49.
Bryant MJ, Baird DS. A case of non-union of the medial cuneiform. Injury. 1993;24(3):207–208.
50.
Buddecke DE, Polk MA, Barp EA. Metatarsal fractures. Clin Podiatr Med Surg. 2010;27(4):601–624.
51.
Bui-Mansfield LT, Thomas WR. Magnetic resonance imaging of stress injury of the cuneiform bones in patients with plantar fasciitis. J Comput Assist Tomogr. 2009;33(4):593–596.
52.
Burne SG, Mahoney CM, Forster BB, et al. Tarsal navicular stress injury: Long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging. Am J Sports Med. 2005;33(12):1875–1881.
53.
Buscemi MJ Jr, Page BJ 2nd. Transcuneiform fracture–cuboid dislocation of the midfoot. J Trauma. 1986;26(3):290–292.
54.
Bush JB, Treuting RJ. Cuboid dislocation associated with a central column Lisfranc injury: A case report. Foot Ankle Int. 2005;26(11):990–993.
55.
Cakir H, Van Vliet-Koppert ST, Van Lieshout EM, et al. Demographics and outcome of metatarsal fractures. Arch Orthop Trauma Surg. 131(2):241–245.
56.
Calder JD, Whitehouse SL, Saxby TS. Results of isolated Lisfranc injuries and the effect of compensation claims. J Bone Joint Surg Br. 2004;86(4):527–530.
57.
Celikoz B, Sengezer M, Isik S, et al. Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines. Microsurgery. 2005;25(1):3–14; discussion 15.
58.
Chandran P, Puttaswamaiah R, Dhillon MS, et al. Management of complex open fracture injuries of the midfoot with external fixation. J Foot Ankle Surg. 2006;45(5):308–315.
59.
Chaney DM. The Lisfranc joint. Clin Podiatr Med Surg. 2010;27(4):547–560.
60.
Cheng Y, Yang H, Sun Z, Ni L, et al. A rare midfoot injury pattern: Navicular-cuneiform and calcaneal-cuboid fracture-dislocation. J Int Med Res. 2012;40(2):824–831.
61.
Chi TD, Toolan BC, Sangeorzan BJ, et al. The lateral column lengthening and medial column stabilization procedures. Clin Orthop Relat Res. 1999;365:81–90.
62.
Cinar C, Arslan H, Ogur S, et al. Crossover replantation of the foot after bilateral traumatic lower extremity amputation. Ann Plast Surg. 2007;58(6):667–672.
63.
Clark DF, Quint HA. Dislocation of a single cuneiform bone. J Bone Joint Surg. 1933;15(1):237–239.
64.
Clayton JM, Hayes AC, Barnes RW. Tissue pressure and perfusion in the compartment syndrome. J Surg Res. 1977;22(4):333–339.
65.
Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint injuries: Primary arthrodesis compared with open reduction and internal fixation. Surgical technique. J Bone Joint Surg Am. 2007;89(suppl 2 pt.1):122–127.
66.
Compson JP. An irreducible medial cuneiform fracture-dislocation. Injury. 1992;23(7):501–502.
67.
Cook KD, Jeffries LC, O’Connor JP, et al. Determining the strongest orientation for “Lisfranc’s screw” in transverse plane tarsometatarsal injuries: A cadaveric study. J Foot Ankle Surg. 2009;48(4):427–431.
68.
Coss HS, Manos RE, Buoncristiani A, et al. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int. 1998;19(8):537–541.
69.
Coulibaly MO, Jones CB, Sietsema DL, Bohay DR, Anderson JG, Ringer JR. Adjunctive Spanning Fixation in the Treatment of Displaced Cuboid Fractures: Results and Complications. OTA Annual Meeting. Vol Scientific Poster #44 Foot, Ankle and Pilon. Baltimore, Maryland; 2010.
70.
Coulibaly MO, Jones CB, Sietsema DL, et al. Results and Complications of 90 Consecutive Cuboid Fractures. Paper presented at: AOFAS 25th Annual Summer Meeting 2009; Vancouver, British Columbia, Canada.
71.
Coulibaly MO, Jones CB, Sietsema DL, et al. Results and Complications of 90 Consecutive Navicular Fractures. Paper presented at: AOFAS 25th Annual Summer Meeting 2009; Vancouver, British Columbia, Canada.
72.
Coulibaly MO, Jones CB, Sietsema DL, et al. Radiographic Analysis of Cuboid Fractures. Abstract number: 24247. 7th SICOT/SIROT Annual International Conference. Gothenburg, Sweden; 2010.
73.
Coulibaly MO, Jones CB, Sietsema DL, et al. Radiographic Analysis of Navicular Fractures. Abstract number: 24250. 7th SICOT/SIROT Annual International Conference. Gothenburg, Sweden; 2010.
74.
Coulibaly MO, Jones CB, Sietsema DL, et al. Results of 90 Consecutive Navicular Fractures. Paper presented at: AAOS 2010 Annual Meeting; March 11 2010, 2010; New Orleans, Louisiana, USA.
75.
Coulibaly MO, Jones CB, Sietsema DL, Schildhauer TA. Adjunct Spanning Internal Fixation of Displaced Navicular Fractures: Results and Complications. OTA Annual Meeting - International Forum. Phoenix, Arizona; 2013.
76.
Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691–697.
77.
Court-Brown CM, Wood AM, Aitken S. The epidemiology of acute sports-related fractures in adults. Injury. 2008;39(12):1365–1372.
78.
Daly N. Fractures and dislocations of the digits. Clin Podiatr Med Surg. 1996;13(2):309–326.
79.
Dameron TB Jr. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am. 1975;57(6):788–792.
80.
Davies MS, Saxby TS. Intercuneiform instability and the “gap” sign. Foot Ankle Int. 1999;20(9):606–609.
81.
Dayton P, Haulard JP. Hallux varus as complication of foot compartment syndrome. J Foot Ankle Surg. 2011;50(4):504–506.
82.
Dedmond BT, Cory JW, McBryde A Jr. The hallucal sesamoid complex. J Am Acad Orthop Surg. 2006;14(13):745–753.
83.
DeLee JC, Curtis R. Subtalar dislocation of the foot. J Bone Joint Surg Am. 1982;64(3):433–437.
84.
Dewar FP, Evans DC. Occult fracture-subluxation of the midtarsal joint. J Bone Joint Surg Br. 1968;50(2):386–388.
85.
Dhawan A, Doukas WC. Acute compartment syndrome of the foot following an inversion injury of the ankle with disruption of the anterior tibial artery. A case report. J Bone Joint Surg Am. 2003;85-A(3):528–532.
86.
Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries? J Bone Joint Surg Br. 1999;81(5):881–885.
87.
Dickson KF, Sullivan MJ, Steinberg B, et al. Noninvasive measurement of compartment syndrome. Orthopedics. 2003;26(12):1215–1218.
88.
DiGiovanni CW. Fractures of the navicular. Foot Ankle Clin. 2004;9(1):25–63.
89.
Ding BC, Weatherall JM, Mroczek KJ, et al. Fractures of the proximal fifth metatarsal: Keeping up with the Joneses. Bull NYU Hosp Jt Dis. 70(1):49–55.
90.
Dixon JH. Isolated dislocation of the tarsal navicular. Injury. 1979;10(3):251.
91.
Dobbs MB, Crawford H, Saltzman C. Peroneus longus tendon obstructing reduction of cuboid dislocation. A report of two cases. J Bone Joint Surg Am. 2001;83-A(9):1387–1391.
92.
Doshi D, Prabhu P, Bhattacharjee A. Dorsal dislocation of the intermediate cuneiform with fracture of the Lisfranc joint: A case report. J Foot Ankle Surg. 2008;47(1):60–62.
93.
Downey MS, Lawrence GA. Digital and Sesamoid Fractures. In: Southerland JT, ed. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Vol 2. 4th ed: Lippincott Williams & Wilkins; 2013:1634–1645.
94.
Drummond DS, Hastings DE. Total dislocation of the cuboid bone. Report of a case. J Bone Joint Surg Br. 1969;51(4):716–718.
95.
Early JS. Fractures and dislocations of the midfoot and forefoot - tarsometatarsal injuries. In: Bucholz RW, Heckman JD, Court-Brown CM, eds. Rockwood and Green’s Fractures in Adults. Vol 2. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:2359–2369.
96.
Early JS. Fractures and dislocations of the midfoot and forefoot. In: Bucholz RW, Heckman JD, Court-Brown CM, eds. Rockwood and Green’s Fractures in Adults. Vol 2. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:2347–2353.
97.
Eberl R, Ruttenstock EM, Singer G, et al. Treatment algorithm for complex injuries of the foot in paediatric patients. Injury. 2011;42(10):1171–1178.
98.
Ebizie AO. Crush fractures of the cuboid from indirect violence. Injury. 1991;22(5):414–416.
99.
Echtermeyer V. [Compartment syndrome]. Langenbecks Arch Chir. 1986;369:527–533.
100.
Echtermeyer V. Compartment syndrome of the foot. Orthopade. 1991;20(1):76–79.
101.
Egol K, Walsh M, Rosenblatt K, et al. Avulsion fractures of the fifth metatarsal base: A prospective outcome study. Foot Ankle Int. 2007;28(5):581–583.
102.
Eichenholtz SN, Levine DB. Fractures of the tarsal navicular bone. Clin Orthop Relat Res. 1964;34:142–157.
103.
Elias I, Dheer S, Zoga AC, et al. Magnetic resonance imaging findings in bipartite medial cuneiform - a potential pitfall in diagnosis of midfoot injuries: A case series. J Med Case Rep. 2008;2:272.
104.
Enderson BL, Reath DB, Meadors J, et al. The tertiary trauma survey: A prospective study of missed injury. J Trauma. 1990;30(6):666–669; discussion 669–670.
105.
Evans J, Beingessner DM, Agel J, et al. Minifragment plate fixation of high-energy navicular body fractures. Foot Ankle Int. 2011;32(5):S485–S492.
106.
Everson LI, Galloway HR, Suh JS, et al. Radiologic case study. Cuboid subluxation. Orthopedics. 1991;14(9):1037, 1044, 1046–1038.
107.
Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am. 1990;72(10):1519–1522.
108.
Fakhouri AJ, Manoli A 2nd. Acute foot compartment syndromes. J Orthop Trauma. 1992;6(2):223–228.
109.
Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome: Course after delayed fasciotomy. J Trauma. 1996;40(3):342–344.
110.
Finnoff JT, Henning PT, Cederholm SK, et al. Accuracy of medial foot compartment pressure testing: A comparison of two techniques. Foot Ankle Int. 2010;31(11):1001–1005.
111.
Fishco WD, Cornwall MW. Gait analysis after talonavicular joint fusion: 2 case reports. J Foot Ankle Surg. 2004;43(4):241–247.
112.
Foster SC, Foster RR. Lisfranc’s tarsometatarsal fracture-dislocation. Radiology. 1976;120(1):79–83.
113.
Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996;10(suppl 1):v–ix, 1–154.
114.
Garfin SR, Mubarak SJ, Evans KL, et al. Quantification of intracompartmental pressure and volume under plaster casts. J Bone Joint Surg Am. 1981;63(3):449–453.
115.
Gelberman RH, Szabo RM, Williamson RV, et al. Tissue pressure threshold for peripheral nerve viability. Clin Orthop Relat Res. 1983;178:285–291.
116.
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285–292.
117.
Goiney RC, Connell DG, Nichols DM. CT evaluation of tarsometatarsal fracture-dislocation injuries. AJR Am J Roentgenol. 1985;144(5):985–990.
118.
Goossens M, De Stoop N. Lisfranc’s fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases. Clin Orthop Relat Res. 1983;176:154–162.
119.
Gopal S, Majumder S, Batchelor AG, et al. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000;82(7):959–966.
120.
Gough DT, Broderick DF, Januzik SJ, et al. Dislocation of the cuboid bone without fracture. Ann Emerg Med. 1988;17(10):1095–1097.
121.
Grambart S, Patel S, Schuberth JM. Naviculocuneiform dislocations treated with immediate arthrodesis: A report of 2 cases. J Foot Ankle Surg. 2005;44(3):228–235.
122.
Griffin NL, Richmond BG. Cross-sectional geometry of the human forefoot. Bone. 2005;37(2):253–260.
123.
Groshar D, Alperson M, Mendes DG, et al. Bone scintigraphy findings in Lisfranc joint injury. Foot Ankle Int. 1995;16(11):710–711.
124.
Guler F, Baz AB, Turan A, et al. Isolated medial cuneiform fractures: Report of two cases and review of the literature. Foot Ankle Spec. 2011;4(5):306–309.
125.
Guo S, Sethi D, Prakash D. Compartment syndrome of the foot secondary to fixation of ankle fracture–a case report. Foot Ankle Surg. 2010;16(3):e72–e75.
126.
Gupta RT, Wadhwa RP, Learch TJ, Herwick SM. Lisfranc injury: imaging findings for this important but often-missed diagnosis. Curr Probl Diagn Radiol. 2008;37(3):115–126.
127.
Haapamaki V, Kiuru M, Koskinen S. Lisfranc fracture-dislocation in patients with multiple trauma: Diagnosis with multidetector computed tomography. Foot Ankle Int. 2004;25(9):614–619.
128.
Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: Analysis of MDCT findings. AJR Am J Roentgenol. 2004;183(3):615–622.
129.
Haddix B, Ellis K, Saylor-Pavkovich E. Lisfranc fracture-dislocation in a female soccer athlete. Int J Sports Phys Ther. 7(2):219–225.
130.
Hansen JST. Functional Reconstruction of the Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.
131.
Hansen ST Jr. Acute fracture in the foot - Lisfranc’s joint fracture-dislocations. Functional Reconstruction of the Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:91–96.
132.
Hansen ST Jr. Acute trauma and fracture Surgery. Functional Reconstruction of the Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.
133.
Hansen ST Jr. Arthrodesis techniques. Functional Reconstruction of the Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:332–338.
134.
Hansen ST Jr. Posttraumatic and degenerative problems in the joints. Functional Reconstruction of the Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:174–178.
135.
Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br. 1982;64(3):349–356.
136.
Hargens AR, Schmidt DA, Evans KL, et al. Quantitation of skeletal-muscle necrosis in a model compartment syndrome. J Bone Joint Surg Am. 1981;63(4):631–636.
137.
Harris GF. Analysis of ankle and subtalar motion during human locomotion. In: Inman VT, ed. The joints of the ankle. Baltimore: Williams & Wilkins; 1976:75–84.
138.
Harris I. Gradual closure of fasciotomy wounds using a vessel loop shoelace. Injury. 1993;24(8):565–566.
139.
Haverstock BD. Foot and ankle imaging in the athlete. Clin Podiatr Med Surg. 2008;25(2):249–262, vi–vii.
140.
Henning A, Gaines RJ, Carr D, et al. Acute compartment syndrome of the foot following fixation of a pilon variant ankle fracture. Orthopedics. 2010;33(12):926.
141.
Henning JA, Jones CB, Sietsema DL, et al. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: A prospective randomized study. Foot Ankle Int. 2009;30(10):913–922.
142.
Hermel MB, Gershon-Cohen J. The nutcracker fracture of the cuboid by indirect violence. Radiology. 1953;60(6):850–854.
143.
Hicks JH. The mechanics of the foot. I. The joints. J Anat. 1953;87(4):345–357.
144.
Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg. 1986;13(4):663–680.
145.
Hidalgo-Ovejero ÃnM, GarcÃ-a-Mata Sn, Ilzarbe-Ibero A, et al. Complete medial dislocation of the first cuneiform: A case report. J Foot Ankle Surg. 2005;44(6):478–482.
146.
Hintermann B. [Biomechanical aspects of muscle-tendon functions]. Orthopade. 1995;24(3):187–192.
147.
Hocker K, Kirner E. [Rare, in plain roentgen unidentifiable severe combination injury of the tarsometatarsal joint]. Unfallchirurgie. 1997;23(5):216–219; discussion 220.
148.
Holbein O, Bauer G, Kinzl L. Fracture of the cuboid in children: Case report and review of the literature. J Pediatr Orthop. 1998;18(4):466–468.
149.
Holstein A, Joldersma RD. Dislocation of first cuneiform in tarsometatarsal fracture-dislocation. J Bone Joint Surg Am. 1950;32A(2):419–421.
150.
Howie CR, Hooper G, Hughes SP. Occult midtarsal subluxation. Clin Orthop Relat Res. 1986;209:206–209.
151.
Hunter JC, Sangeorzan BJ. A nutcracker fracture: cuboid fracture with an associated avulsion fracture of the tarsal navicular. AJR Am J Roentgenol. 1996;166(4):888.
152.
Husain ZS, DeFronzo DJ. Relative stability of tension band versus two-cortex screw fixation for treating fifth metatarsal base avulsion fractures. J Foot Ankle Surg. 2000;39(2):89–95.
153.
Ip KY, Lui TH. Isolated dorsal midtarsal (Chopart) dislocation: A case report. J Orthop Surg (Hong Kong). 2006;14(3):357–359.
154.
Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of tertiary trauma survey. J Trauma. 1998;44(6):1000–1006; discussion 1006–1007.
155.
Janzing HM, Broos PL. Dermatotraction: an effective technique for the closure of fasciotomy wounds: A preliminary report of fifteen patients. J Orthop Trauma. 2001;15(6):438–441.
156.
Jeffers RF, Tan HB, Nicolopoulos C, et al. Prevalence and patterns of foot injuries following motorcycle trauma. J Orthop Trauma. 2004;18(2):87–91.
157.
Jeng SF, Hsieh CH, Lin TS, et al. Classification and reconstruction options in foot plantar skin avulsion injuries: Follow-up. Plast Reconstr Surg. 2003;112(1):220–221.
158.
Jeng SF, Wei FC. Classification and reconstructive options in foot plantar skin avulsion injuries. Plast Reconstr Surg. 1997;99(6):1695–1703; discussion 1704–1695.
159.
Johnson GF. Pediatric Lisfranc injury: “bunk bed” fracture. AJR Am J Roentgenol. 1981;137(5):1041–1044.
160.
Johnson JT, Labib SA, Fowler R. Intramedullary screw fixation of the fifth metatarsal: An anatomic study and improved technique. Foot Ankle Int. 2004;25(4):274–277.
161.
Johnstone AJ, Maffulli N. Primary fusion of the talonavicular joint after fracture dislocation of the navicular bone. J Trauma. 1998;45(6):1100–1102.
162.
Jones CB, Coulibaly MO, Sietsema DL, et al. Functional Outcome of Midfoot Fractures. Paper presented at: AAOS 2011 Annual Meeting; March 11 2010, 2011; San Diego, California, USA.
163.
Jones CB, Coulibaly MO. Midfoot fractures. lisfranc, cuboid, navicular. In: Archdeacon MT, Anglen JO, Ostrum RF, Herscovici D, eds. Prevention and Management of Common Fracture Complications. Thorofare, NJ: Slack; 2011:329–344.
164.
Jowett A, Birks C, Blackney M. Chronic exertional compartment syndrome in the medial compartment of the foot. Foot Ankle Int. 2008;29(8):838–841.
165.
Julsrud ME. Osteonecrosis of the tibial and fibular sesamoids in an aerobics instructor. J Foot Ankle Surg. 1997;36(1):31–35.
166.
Jupiter DC, Shibuya N, Clawson LD, et al. Incidence and risk factors for amputation in foot and ankle trauma. J Foot Ankle Surg. 51(3):317–322.
167.
Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential ligament sectioning. J Bone Joint Surg Am. 2007;89(10):2225–2232.
168.
Kakagia D, Karadimas EJ, Drosos G, et al. Wound closure of leg fasciotomy: Comparison of vacuum-assisted closure versus shoelace technique. A randomised study. Injury. (0).
169.
Kamel R, Sakla FB. Anatomical compartments of the sole of the human foot. Anat Rec. 1961;140:57–60.
170.
Karaindros K, Arealis G, Papanikolaou A, et al. Irreducible Lisfranc dislocation due to the interposition of the tibialis anterior tendon: Case report and literature review. Foot Ankle Surg. 2010;16(3):e68–e71.
171.
Keeling JJ, Hsu JR, Shawen SB, et al. Strategies for managing massive defects of the foot in high-energy combat injuries of the lower extremity. Foot Ankle Clin. 2010;15(1):139–149.
172.
Khati M, Briggs PJ. Isolated plantar dislocation of the intermediate cuneiform: A case report and review of the literature. The Foot. 2002;11:215–217.
173.
Kimura K, Adachi H, Ogawa M, et al. Supplementary transverse wire fixation through cuneiforms and cuboid in combination with a screw for the comminuted tarsal navicular fractures. Arch Orthop Trauma Surg. 2002;122(7):410–413.
174.
Kinner B, Tietz S, Muller F, et al. Outcome after complex trauma of the foot. J Trauma. 2011;70(1):159–168; discussion 168.
175.
Klaue K. Chopart fractures. Injury. 2004;35(Suppl 2):SB64–SB70.
176.
Kollmannsberger A, De Boer P. Isolated calcaneo-cuboid dislocation: Brief report. J Bone Joint Surg Br. 1989;71(2):323.
177.
Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am. 1996;78(11):1665–1676.
178.
Kou JX, Fortin PT. Commonly missed peritalar injuries. J Am Acad Orthop Surg. 2009;17(12):775–786.
179.
Kummer B. Morphologie und Biomechanik des Sprunggelenkes und des Fußes. In: Kummer B, ed. Biomechanik—Form und Funktion des Bewegungsapparates. Cologne: Deutscher Ärzte-Verlag; 2005:335–376.
180.
Kuo PF, Ma YC, Chen CW. Tarsometatarsal dislocation or fracture-dislocation. Chin Med J (Engl). 1964;83:563–568.
181.
Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82-A(11):1609–1618.
182.
Kura H, Luo ZP, Kitaoka HB, et al. Mechanical behavior of the Lisfranc and dorsal cuneometatarsal ligaments: In vitro biomechanical study. J Orthop Trauma. 2001;15(2):107–110.
183.
Kym MR, Worsing RA Jr. Compartment syndrome in the foot after an inversion injury to the ankle. A case report. J Bone Joint Surg Am. 1990;72(1):138–139.
184.
Lawendy AR, Sanders DW, Bihari A, et al. Compartment syndrome-induced microvascular dysfunction: An experimental rodent model. Can J Surg. 54(3):194–200.
185.
Lee CA, Birkedal JP, Dickerson EA, et al. Stabilization of Lisfranc joint injuries: A biomechanical study. Foot Ankle Int. 2004;25(5):365–370.
186.
Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: tarsal coalition. Foot Ankle Int. 2006;27(12):1163–1169.
187.
Lidtke RH, Patel D, Muehleman C. Calcaneal bone mineral density and mechanical strength of the metatarsals. J Am Podiatr Med Assoc. 2000;90(9):435–440.
188.
Liu DS, Sofiadellis F, Ashton M, et al. Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma. Injury. 2012;43(6):772–778.
189.
Lokiec F, Siev-Ner I, Pritsch M. Chronic compartment syndrome of both feet. J Bone Joint Surg Br. 1991;73(1):178–179.
190.
Longino D, Buckley RE. Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: Is it helpful? J Orthop Trauma. 2001;15(4):280–286.
191.
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88(3):514–520.
192.
Lynch JE, Lynch JK, Cole SL, Carter JA, Hargens AR. Noninvasive monitoring of elevated intramuscular pressure in a model compartment syndrome via quantitative fascial motion. J Orthop Res. 2009;27(4):489–494.
193.
Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg Br. 1975;57(1):89–97.
194.
Maitra R, DeGnore LT. Isolated dislocation of the middle cuneiform in a farmer: A case report and review of the literature. Foot Ankle Int. 1997;18(11):735–738.
195.
Mandracchia VJ, Mandi DM, Toney PA, et al. Fractures of the forefoot. Clin Podiatr Med Surg. 2006;23(2):283–301, vi.
196.
Mann RA, Prieskorn D, Sobel M. Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone Joint Surg Am. 1996;78(9):1376–1385.
197.
Manoli A 2nd. Compartment syndromes of the foot: Current concepts. Foot Ankle. 1990;10(6):340–344.
198.
Manoli A 2nd, Fakhouri AJ, Weber TG. Concurrent compartment syndromes of the foot and leg. Foot Ankle. 1993;14(6):339.
199.
Manoli A 2nd, Hansen ST Jr. Screw hole preparation in foot surgery. Foot Ankle. 1990;11(2):105–106.
200.
Manoli A 2nd, Smith DG, Hansen ST Jr. Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res. 1993;292:309–314.
201.
Manoli A 2nd, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle. 1990;10(5):267–275.
202.
Marek DJ, Copeland GE, Zlowodzki M, Cole PA. The application of dermatotraction for primary skin closure. Am J Surg. 2005;190(1):123–126.
203.
Mars M, Hadley GP. Failure of pulse oximetry in the assessment of raised limb intracompartmental pressure. Injury. 1994;25(6):379–381.
204.
Marsh JL, Slongo TF, Agel J, et al. Dislocation Region Foot and Ankle (80). Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(suppl 10):S125–S128.
205.
Marsh JL, Slongo TF, Agel J, et al. Foot (81-89). Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(suppl 10):S89–S94.
206.
Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(suppl 10):S1–S133.
207.
Marsh JL, Slongo TF, Agel J, et al. Metatarsals (87). Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S95–S98.
208.
Marsh JL, Slongo TF, Agel J, et al. Phalanx - Foot (88). Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S99–S102.
209.
Marsh JL, Slongo TF, Agel J, et al. Tarsal-metatarsal dislocation (80-C5). Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S126–127.
210.
Marshall MP. Compartment syndrome of the foot in children. J Bone Joint Surg Am. 1995;77(11):1785.
211.
Marshall P. The rehabilitation of overuse foot injuries in athletes and dancers. Clin Sports Med. 1988;7(1):175–191.
212.
Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. Am J Sports Med. 1992;20(2):169–175.
213.
Maskill JD, Bohay DR, Anderson JG. First ray injuries. Foot Ankle Clin. 2006;11(1):143–163, ix–x.
214.
Maxwell JR. Open or closed treatment of metatarsal fractures. Indications and techniques. J Am Podiatry Assoc. 1983;73(2):100–106.
215.
McBryde AM Jr, Anderson RB. Sesamoid foot problems in the athlete. Clin Sports Med. 1988;7(1):51–60.
216.
McGlamry ED, Southerland JT. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. 4th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins Health.
217.
McKeever FM. Fractures of tarsal and metatarsal bones. Surg Gynecol Obstet. 1950;90(6):735–745.
218.
Meister K, Demos HA. Fracture dislocation of the tarsal navicular with medial column disruption of the foot. J Foot Ankle Surg. 1994;33(2):135–137.
219.
Middleton DK, Johnson JE, Davies JF. Exertional compartment syndrome of bilateral feet: A case report. Foot Ankle Int. 1995;16(2):95–96.
220.
Miersch D, Wild M, Jungbluth P, et al. A transcuneiform fracture-dislocation of the midfoot. Foot (Edinb). 2010;21(1):45–47.
221.
Migues A, Slullitel G, Vescovo A, et al. Peripheral foot blockade versus popliteal fossa nerve block: a prospective randomized trial in 51 patients. J Foot Ankle Surg. 2005;44(5):354–357.
222.
Miller CM, Winter WG, Bucknell AL, et al. Injuries to the midtarsal joint and lesser tarsal bones. J Am Acad Orthop Surg. 1998;6(4):249–258.
223.
Miozzari HH, Gerard R, Stern R, et al. Acute, exertional medial compartment syndrome of the foot in a high-level athlete: A case report. Am J Sports Med. 2008;36(5):983–986.
224.
Mittlmeier T. Acute compartment syndrome and complex trauma of the foot. Unfallchirurg. 2011;114(10):893–900.
225.
Mittlmeier T, Beck M. [Injuries of the midfoot]. Chirurg. 2011;82(2):169–186; quiz 187–168.
226.
Mittlmeier T, Machler G, Lob G, et al. Compartment syndrome of the foot after intraarticular calcaneal fracture. Clin Orthop Relat Res. 1991;269:241–248.
227.
Mizel MS, Hwang JJ, Temple HT. Closed reduction of a lesser toe fracture. Foot Ankle Int. 1998;19(8):568–569.
228.
Moed BR, Thorderson PK. Measurement of intracompartmental pressure: A comparison of the slit catheter, side-ported needle, and simple needle. J Bone Joint Surg Am. 1993;75(2):231–235.
229.
Mologne TS, Lundeen JM, Clapper MF, et al. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33(7):970–975.
230.
Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations: Assessment and treatment. J Orthop Sports Phys Ther. 1994;20(4):220–226.
231.
Morton DJ. Dorsal hypermobility of the first metatarsal segment: part III. In: DJ M, ed. The Human Foot: Its Evolution, Physiology, and Functional Disorders. New York, NY: Columbia University Press; 1935:187–195.
232.
Mueller TJ. Acquired flatfoot secondary to tibialis posterior dysfunction: biomechanical aspects. J Foot Surg. 1991;30(1):2–11.
233.
Mulier T, Reynders P, Dereymaeker G, et al. Severe Lisfrancs injuries: Primary arthrodesis or ORIF? Foot Ankle Int. 2002;23(10):902–905.
234.
Mulier T, Reynders P, Sioen W, et al. The treatment of Lisfranc injuries. Acta Orthop Belg. 1997;63(2):82–90.
235.
Müller AO. Classification of fractures: Long bones. AO Publishing Switzerland [PDF]. Available at: http://www.aofoundation.org/AOFileServer/PortalFiles?FilePath=/Extranet2007/active/_att/wor/act/fracture_classif/mueller_ao_class.pdf.
236.
Müller ME, Nazarian S, Koch P. Classification AO des fractures: les os longs. Berlin, Heidelberg, New York: Springer-Verlag; 1987.
237.
Murphy GA. Fractures and dislocations of foot. In: Canale ST, ed. Campbell’s Operative Orthopaedics. Vol 4. 10th ed. St. Louis, MO: Mosby, Inc.; 2002.
238.
Murray SR, Reeder M, Ward T, et al. Navicular stress fractures in identical twin runners: High-risk fractures require structured treatment. Phys Sportsmed. 2005;33(1):28–33.
239.
Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989;20(4):655–664.
240.
Myerson M. Diagnosis and treatment of compartment syndrome of the foot. Orthopedics. 1990;13(7):711–717.
241.
Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop Relat Res. 1993;290:142–150.
242.
Myerson MS. Experimental decompression of the fascial compartments of the foot–the basis for fasciotomy in acute compartment syndromes. Foot Ankle. 1988;8(6):308–314.
243.
Myerson MS. The diagnosis and treatment of injury to the tarsometatarsal joint complex. J Bone Joint Surg Br. 1999;81(5):756–763.
244.
Myerson MS, Cerrato RA. Current management of tarsometatarsal injuries in the athlete. J Bone Joint Surg Am. 2008;90(11):2522–2533.
245.
Myerson MS, Fisher RT, Burgess AR, et al. Fracture dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225–242.
246.
Myerson MS, McGarvey WC, Henderson MR, et al. Morbidity after crush injuries to the foot. J Orthop Trauma. 1994;8(4):343–349.
247.
Naidu V, Singh SK. Cerclage wire fixation of navicular body fractures – a treatment based on mechanism of injury. Foot Ankle Int. 2005;26(3):267–269.
248.
Nashi M, Banerjee B. Isolated plantar dislocation of the middle cuneiform–a case report. Injury. 1997;28(9-10):704–706.
249.
Nishi H, Takao M, Uchio Y, et al. Isolated plantar dislocation of the intermediate cuneiform bone. A case report. J Bone Joint Surg Am. 2004;86-A(8):1772–1777.
250.
Nithyananth M, Boopalan PR, Titus VT, et al. Long-term outcome of high-energy open Lisfranc injuries: A retrospective study. J Trauma. 70(3):710–716.
251.
Niva MH, Sormaala MJ, Kiuru MJ, et al. Bone stress injuries of the ankle and foot: An 86-month magnetic resonance imaging based study of physically active young adults. Am J Sports Med. 2007;35(4):643–649.
252.
Norfray JF, Geline RA, Steinberg RI, et al. Subtleties of Lisfranc fracture-dislocations. AJR Am J Roentgenol. 1981;137(6):1151–1156.
253.
Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871–878.
254.
Ojike NI, Roberts CS, Giannoudis PV. Foot compartment syndrome: a systematic review of the literature. Acta Orthop Belg. 2009;75(5):573–580.
255.
Olson RC, Mendicino SS, Rockett MS. Isolated medial cuneiform fracture: Review of the literature and report of two cases. Foot Ankle Int. 2000;21(2):150–153.
256.
Osher LS, DeMore M 3rd, Atway S, et al. Extended pedal imaging via modifications of the traditional forefoot axial radiographic study: Teaching new tricks to an old dog? an initial report with case presentations. J Am Podiatr Med Assoc. 2008;98(3):171–188.
257.
Ouzounian TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle. 1989;10(3):140–146.
258.
Panchbhavi VK, Vallurupalli S, Yang J, et al. Screw fixation compared with suture-button fixation of isolated Lisfranc ligament injuries. J Bone Joint Surg Am. 2009;91(5):1143–1148.
259.
Pao DG, Keats TE, Dussault RG. Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: The need for an additional projection. AJR Am J Roentgenol. 2000;175(2):549–552.
260.
Patterson RH, Petersen D, Cunningham R. Isolated fracture of the medial cuneiform. J Orthop Trauma. 1993;7(1):94–95.
261.
Pearson JB. Fractures of Base of Fifth Metatarsal. BMJ. 1962;1(5284):1052–1054.
262.
Pelt CE, Bachus KN, Vance RE, et al. A biomechanical analysis of a tensioned suture device in the fixation of the ligamentous Lisfranc injury. Foot Ankle Int. 2011;32(4):422–431.
263.
Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27(3):172–174.
264.
Pfeifer R, Pape HC. Missed injuries in trauma patients: A literature review. Patient Saf Surg. 2008;2:20.
265.
Pfitzner W. Beiträge zur Kenntniss des menschlichen Extremitätenskelets. In: Schwalbe G, ed. Morphologische Arbeiten. Vol Bd. 6 (1896). Jena: G. Fischer; 1896:245–528.
266.
Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin. 2003;8(1):61–71.
267.
Pinnes SJ, Sangeorzan BJ. Fractures of the tarsal bones. In: Sangeorzan BJ, ed. The Traumatic Foot. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2001:41–53.
268.
Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am. 2001;32(1):21–33.
269.
Pinzur MS, Gottschalk FA, Pinto MA, et al, American Academy of Orthopaedics. Controversies in lower-extremity amputation. J Bone Joint Surg Am. 2007;89(5):1118–1127.
270.
Pretterklieber ML, Wanivenhaus A. The arterial supply of the sesamoid bones of the hallux: The course and source of the nutrient arteries as an anatomical basis for surgical approaches to the great toe. Foot Ankle. 1992;13(1):27–31.
271.
Probst C, Richter M, Lefering R, et al. Incidence and significance of injuries to the foot and ankle in polytrauma patients–an analysis of the Trauma Registry of DGU. Injury. 2010;41(2):210–215.
272.
Quénu E, Küss G. Étude sur les luxations du metatarse (luxations métatarsotarsiennes) du diastasis entre le 1er et le 2e metatarsien. Rev Chir (Paris). 1909;39:281–336, 720–791, 1093–1134.
273.
Quirk R. Ballet injuries: the Australian experience. Clin Sports Med. 1983;2(3):507–514.
274.
Raikin SM, Elias I, Dheer S, et al. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91(4):892–899.
275.
Rajapakse B, Edwards A, Hong T. A single surgeon’s experience of treatment of Lisfranc joint injuries. Injury. 2006;37(9):914–921.
276.
Rammelt S, Biewener A, Grass R, et al. Foot injuries in the polytraumatized patient. Unfallchirurg. 2005;108(10):858–865.
277.
Rammelt S, Grass R, Schikore H, et al. [Injuries of the Chopart joint]. Unfallchirurg. 2002;105(4):371–383; quiz 384–375.
278.
Rammelt S, Grass R, Zwipp H. [Nutcracker fractures of the navicular and cuboid]. Ther Umsch. 2004;61(7):451–457.
279.
Rammelt S, Schneiders W, Schikore H, et al. Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. J Bone Joint Surg Br. 2008;90(11):1499–1506.
280.
Rammelt S, Schneiders W, Zwipp H. [Corrective tarsometatarsal arthrodesis for malunion after fracture-dislocation]. Orthopade. 2006;35(4):435–442.
281.
Randt T, Dahlen C, Schikore H, et al. [Dislocation fractures in the area of the middle foot–injuries of the Chopart and Lisfranc joint]. Zentralbl Chir. 1998;123(11):1257–1266.
282.
Rao H. Complete open dislocation of the navicular: a case report. The Journal of Foot and Ankle Surgery. 2012;51(2):209–211.
283.
Reach JS Jr, Amrami KK, Felmlee JP, et al. Anatomic compartments of the foot: a 3-Tesla magnetic resonance imaging study. Clin Anat. 2007;20(2):201–208.
284.
Reach JS Jr, Amrami KK, Felmlee JP, et al. The compartments of the foot: a 3-tesla magnetic resonance imaging study with clinical correlates for needle pressure testing. Foot Ankle Int. 2007;28(5):584–594.
285.
Richardson EG. Injuries to the hallucal sesamoids in the athlete. Foot Ankle. 1987;7(4):229–244.
286.
Richter J, Schulze W, Klaas A, et al. Compartment syndrome of the foot: An experimental approach to pressure measurement and release. Arch Orthop Trauma Surg. 2008;128(2):199–204.
287.
Richter M, Thermann H, Wippermann B, et al. Foot fractures in restrained front seat car occupants: A long-term study over twenty-three years. J Orthop Trauma. 2001;15(4):287–293.
288.
Richter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C. Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int. 2004;25(5):340–348.
289.
Richter M, Wippermann B, Krettek C, et al. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int. 2001;22(5):392–398.
290.
Ross G, Cronin R, Hauzenblas J, et al. Plantar ecchymosis sign: A clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma. 1996;10(2):119–122.
291.
Rymaszewski LA, Robb JE. Mechanism of fracture-dislocation of the navicular: Brief report. J Bone Joint Surg Br. 1988;70(3):492.
292.
Sammarco GJ, Hockenbury RT. Biomechanics of the foot and ankle. In: Nordin M, Frankel VH, eds. Basic Biomechanics of the Musculoskeletal System. 3rd ed. New York City: Lippincott Williams & Wilkins; 2001:222–255.
293.
Sangeorzan BJ, Benirschke SK, Mosca V, et al. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am. 1989;71(10):1504–1510.
294.
Sangeorzan BJ, Hansen ST Jr. Early and late posttraumatic foot reconstruction. Clin Orthop Relat Res. 1989;243:86–91.
295.
Sangeorzan BJ, Swiontkowski MF. Displaced fractures of the cuboid. J Bone Joint Surg Br. 1990;72(3):376–378.
296.
Sangeorzan BJ, Veith RG, Hansen ST Jr. Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis. Foot Ankle. 1990;10(4):193–200.
297.
Sanli I, Hermus J, Poeze M. Primary internal fixation and soft-tissue reconstruction in the treatment for an open Lisfranc fracture-dislocation. Musculoskelet Surg. 2012.
298.
Sarage AL, Gambardella GV, Fullem B, et al. Cuboid-navicular tarsal coalition: report of a small case series with description of a surgical approach for resection. J Foot Ankle Surg. 51(6):783–786.
299.
Sarrafian SK. Functional characteristics of the foot and plantar aponeurosis under tibiotalar loading. Foot Ankle. 1987;8(1):4–18.
300.
Sarrafian SK, Kelikian AS. Retaining Systems and Compartments. In: Kelikian AS, ed. Anatomy of the Foot and Ankle: Descriptive, Topographical, Functional. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011:120–162.
301.
Sarrafian SK. Functional characteristics of the foot and plantar aponeurosis under tibiotalar loading. Foot Ankle. 1987;8(1):4–18.
302.
Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographical, Functional. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011.
303.
Sauers RJ, Diiorio EJ, Weiss CB. A Lisfranc’s fracture-dislocation in a collegiate football player. J Athl Train. 1992;27(1):24–26.
304.
Saxena A, Fullem B. Navicular stress fractures: a prospective study on athletes. Foot Ankle Int. 2006;27(11):917–921.
305.
Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg. 2000;39(2):96–103.
306.
Saxena A, Krisdakumtorn T. Return to activity after sesamoidectomy in athletically active individuals. Foot Ankle Int. 2003;24(5):415–419.
307.
Schad W. Der Fuß des Menschen-ein lange verkanntes datail seiner evolution. In: Hamel J, ed. D.A.F. Vol 2; 2000:10–13.
308.
Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma. 2003;17(7):513–520.
309.
Schiller MG, Ray RD. Isolated dislocation of the medial cuneiform bone–a rare injury of the tarsus. A case report. J Bone Joint Surg Am. 1970;52(8):1632–1636.
310.
Senaran H, Mason D, De Pellegrin M. Cuboid fractures in preschool children. J Pediatr Orthop. 2006;26(6):741–744.
311.
Simonian PT, Vahey JW, Rosenbaum DM, Mosca VS, Staheli LT. Fracture of the cuboid in children. A source of leg symptoms. J Bone Joint Surg Br. 1995;77(1):104–106.
312.
Shapiro MS, Wascher DC, Finerman GA. Rupture of Lisfranc’s ligament in athletes. Am J Sports Med. 1994;22(5):687–691.
313.
Sheibani-Rad S, Coetzee JC, Giveans MR, et al. Arthrodesis versus ORIF for Lisfranc fractures. Orthopedics. 35(6):e868–e873.
314.
Shereff MJ. Fractures of the forefoot. Instr Course Lect. 1990;39:133–140.
315.
Sherief TI, Mucci B, Greiss M. Lisfranc injury: how frequently does it get missed? And how can we improve? Injury. 2007;38(7):856–860.
316.
Silas SI, Herzenberg JE, Myerson MS, et al. Compartment syndrome of the foot in children. J Bone Joint Surg Am. 1995;77(3):356–361.
317.
Spector FC, Karlin JM, Scurran BL, et al. Lesser metatarsal fractures. Incidence, management, and review. J Am Podiatry Assoc. 1984;74(6):259–264.
318.
Stark WA. Occult fracture-subluxation of the midtarsal joint. Clin Orthop Relat Res. 1973;93:291–292.
319.
Starosta D, Sacchetti AD, Sharkey P. Calcaneal fracture with compartment syndrome of the foot. Ann Emerg Med. 1988;17(8):856–858.
320.
Stavlas P, Roberts CS, Xypnitos FN, et al. The role of reduction and internal fixation of Lisfranc fracture-dislocations: A systematic review of the literature. Int Orthop. 2010;34(8):1083–1091.
321.
Stewart IM. Jones’s fracture: Fracture of base of fifth metatarsal. Clin Orthop. 1960;16:190–198.
322.
Stratmann B, Strosche H, Beyer HK. Diagnosis of fractures of the cuneiform bone and injuries of tasometatarsal joints with a modified X-ray technique. Unfallchirurg. 1988;91(6):282–285.
323.
Strohm PC, Schwering L, Mehlhorn A, et al. Injuries of the midfoot in children. Unfallchirurg. 2006;109(12):1094–1098.
324.
Swoboda B, Scola E, Zwipp H. Surgical treatment and late results of foot compartment syndrome. Unfallchirurg. 1991;94(5):262–266.
325.
Taylor SF, Heidenreich D. Isolated medial cuneiform fracture: A special forces soldier with a rare injury. South Med J. 2008;101(8):848–849.
326.
Templeman DC, Varecka TF, Schmidt RD. Economic costs of missed compartment syndromes. J Orthop Trauma. 1993;7(2):180.
327.
Teng AL, Pinzur MS, Lomasney L, et al. Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot Ankle Int. 2002;23(10):922–926.
328.
Teo YH, Verhoeven W. Plantar dislocation of lateral tarsometatarsal joint: A case of subtle Lisfranc injury. Ann Acad Med Singapore. 2004;33(3):362–364.
329.
Thakur NA, McDonnell M, Got CJ, et al. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am. 2012;94(11):1030–1035.
330.
Thompson MC, Mormino MA. Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg. 2003;11(4):260–267.
331.
Thomson CB, Greaves I. Missed injury and the tertiary trauma survey. Injury. 2008;39(1):107–114.
332.
Thordarson DB. Fractures of the midfoot and forefoot. In: Myerson MS, ed. Foot and Ankle Disorders. Vol 2. Philadelphia, PA: W.B. Saunders; 2000:1265–1296.
333.
Torg JS, Balduini FC, Zelko RR, et al. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984;66(2):209–214.
334.
Torg JS, Moyer J, Gaughan JP, et al. Management of tarsal navicular stress fractures: Conservative versus surgical treatment: A meta-analysis. Am J Sports Med. 2010;38(5):1048–1053.
335.
Tountas AA. Occult fracture-subluxation of the midtarsal joint. Clin Orthop Relat Res. 1989;243:195–199.
336.
Towne LC, Blazina ME, Cozen LN. Fatigue fracture of the tarsal navicular. J Bone Joint Surg Am. 1970;52(2):376–378.
337.
Trevino SG, Kodros S. Controversies in tarsometatarsal injuries. Orthop Clin North Am. 1995;26(2):229–238.
338.
Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: Are clinical findings predictive of the disorder? J Orthop Trauma. 2002;16(8):572–577.
339.
Urteaga AJ, Lynch M. Fractures of the central metatarsals. Clin Podiatr Med Surg. 1995;12(4):759–772.
340.
Vaishya R, Patrick JH. Isolated dorsal fracture-dislocation of the tarsal navicular. Injury. 1991;22(1):47–48.
341.
van den Brand JG, Verleisdonk EJ, van der Werken C. Near infrared spectroscopy in the diagnosis of chronic exertional compartment syndrome. Am J Sports Med. 2004;32(2):452–456.
342.
Van Vliet-Koppert ST, Cakir H, Van Lieshout EM, et al. Demographics and functional outcome of toe fractures. J Foot Ankle Surg. 50(3):307–310.
343.
Vertullo CJ, Easley ME, Nunley JA. The transverse dorsal approach to the Lisfranc joint. Foot Ankle Int. 2002;23(5):420–426.
344.
Volkmann RV. Die ischämischen Muskellähmungen und Kontrakturen. Zentralbl Chir. 1881;8:801–803.
345.
Wadsworth DJ, Eadie NT. Conservative management of subtle Lisfranc joint injury: A case report. J Orthop Sports Phys Ther. 2005;35(3):154–164.
346.
Wang CL, Shieh JY, Wang TG, et al. Sonographic detection of occult fractures in the foot and ankle. J Clin Ultrasound. 1999;27(8):421–425.
347.
Watson AD, Kelikian AS. Thomas splint, calcaneus fracture, and compartment syndrome of the foot: A case report. J Trauma. 1998;44(1):205–208.
348.
Waugh W. The ossification and vascularisation of the tarsal navicular and their relation to Kohler’s disease. J Bone Joint Surg Br. 1958;40-B(4):765–777.
349.
Weber M, Locher S. Reconstruction of the cuboid in compression fractures: short to midterm results in 12 patients. Foot Ankle Int. 2002;23(11):1008–1013.
350.
Whitesides TE, Haney TC, Morimoto K, et al. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975;113:43–51.
351.
Wiemann JM, Ueno T, Leek BT, Yost WT, Schwartz AK, Hargens AR. Noninvasive measurements of intramuscular pressure using pulsed phase-locked loop ultrasound for detecting compartment syndromes: a preliminary report. J Orthop Trauma. 2006;20(7):458–463.
352.
Wiger P, Styf JR. Effects of limb elevation on abnormally increased intramuscular pressure, blood perfusion pressure, and foot sensation: an experimental study in humans. J Orthop Trauma. 1998;12(5):343–347.
353.
Wiger P, Blomqvist G, Styf J. Wound closure by dermatotraction after fasciotomy for acute compartment syndrome. Scand J Plast Reconstr Surg Hand Surg. 2000;34(4):315–320.
354.
Wiger P, Zhang Q, Styf J. The effects of limb elevation and increased intramuscular pressure on nerve and muscle function in the human leg. Eur J Appl Physiol. 2000;83(1):84–88.
355.
Wiley JJ. The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg Br. 1971;53(3):474–482.
356.
Wiley JJ. Tarso-metatarsal joint injuries in children. J Pediatr Orthop. 1981;1(3):255–260.
357.
Wilson DW. Injuries of the tarso-metatarsal joints: Etiology, Classification and Results of Treatment. Journal of Bone & Joint Surgery, British Volume. 1972;54-B(4):677–686.
358.
Wood Jones FW. Structure and Function as Seen in the Foot. London: Bailliere, Tidall & Cox; 1944.
359.
Wood T, Sameem M, Avram R, et al. A systematic review of early versus delayed wound closure in patients with open fractures requiring flap coverage. J Trauma Acute Care Surg. 2012;72(4):1078–1085.
360.
Wülker N, Stephens MM, Cracchiolo III. A. Operationsatlas Fuß und Sprunggelenk. 2nd ed. Stuttgart - New York: Georg Thieme Verlag; 2009.
361.
Zhang H, Min L, Wang GL, et al. Primary open reduction and internal fixation with headless compression screws in the treatment of Chinese patients with acute Lisfranc joint injuries. J Trauma Acute Care Surg. 2012;72(5):1380–1385.
362.
Ziv I, Mosheiff R, Zeligowski A, et al. Crush injuries of the foot with compartment syndrome: Immediate one-stage management. Foot Ankle. 1989;9(4):185–189.
363.
Zwipp, H. Reconstructive measures for the foot after compartment syndrome. Unfallchirurg. 1991;94(5):274–279.
364.
Zwipp H. Chirurgie des Fußes. Vol 1. Wien New York, NY: Springer-Verlag; 1994.
365.
Zwipp H, Dahlen C, Randt T, et al. [Complex trauma of the foot]. Orthopade. 1997;26(12):1046–1056.
366.
Zwipp H, Rammelt S. [Posttraumatic deformity correction at the foot]. Zentralbl Chir. 2003;128(3):218–226.