PROF.

RANA DILAWAIZ NADEEM

MCh Orth, MD, FRCS Trauma & Orth (UK)
Department of Orthopaedic Surgery
King Edward Medical University /
Mayo Hospital Lahore.
Domain of the topic
Phalangeal fractures
Metatarsal fractures
Metatarsophalageal joint injuries
Midfoot injuries excluding Lisfranc injury
Ankle pilon fracture
Lisfranc injury
Talus fractures
Calcaneus fractures
 Objectives of Presentation
Lisfranc injury

Talus fractures

Calcaneus fractures
LISFRANC INJURY
Pioneering French
surgeon and gynecologist.

The Lisfranc joint and the Lisfranc

fracture are named after him.
Anatomy
Mid foot
Bones held in place by
ligaments.
No ligament connection
between 1st and 2nd metatarsals
Lisfranc joint complex
consists of three articulations
including
Tarsometatarsal articulation.
Intermetatarsal articulation.
Intertarsal articulations.
Stability of TMT joint and ligaments
The trapezoidal shape of the middle
three MT bases and their associated
cuneiforms produce a stable arch
referred to as the transverse or
Roman arch.
The keystone to the transverse arch
is the second TMT joint, a product
of the recessed middle cuneiform
Mechanism of Injury
Direct trauma/crush
Twisting injuries lead to
forceful abduction of the
forefoot, often resulting in
a 2nd metatarsal base
fracture and/or
compression fracture of
the cuboid ( nut cracker)
Plantar flexion with axial
loading
Low or high energy
(beware of associated
injuries)
Clinical Presentation.
Variable
Pain, especially with weight
bearing activity
Plantar echymosis
Dorsal tenderness, edema
Mild discomfort
Deformity/instability
High index of suspicion based on
mechanism.
Diagnosis.
Physical exam
view X-Ray (AP, lateral,
medial oblique)/
weight-bearing films
helpful.

20% of films are negative

initially. Repeat films at 7-
14 days, consider CT/MRI.

Often mistaken as a sprain-

when in doubt, splint and
refer to orthopedics.
Clinical Findings.
The most consistent
finding is misalignment
along the medial side of
second MT and second
cuneiform
The medial cuneiform-
second MT space should
be evaluated for the
"fleck sign" indicating
avulsion of the Lisfranc
ligament.
Classification;
Homolateral
All of the metatarsals are dislocated to the same side
Usually involves the 2nd through 5th dislocated laterally

Divergent
May be associated with a fracture of the 1st cuneiform
Usually involves medial displacement of the 1st
metatarsal and lateral displacement of 2nd-5th
metatarsals
Classification X-Rays
Homolateral Divergent
Classification types;
 Management
STABILITY;
The definition of instability presently is defined as a
greater than 2-mm shift in normal joint position.
Diastasis between the first and second MT in the injured
midfoot is considered normal provided that it measures
<2.7 mm.

GOALS OF TREATMENT;
Painless
Plantigrade
Stable foot
NON OPERATE TREATMENT
<2-mm displacement of the tarsometatarsal joint in any plane.

Short leg non-weight-

bearing cast for 6 weeks

Weight bearing cast for

an additional 4 to 6
weeks
Recheck stability with
stress views at 10 days
from injury
Surgical Management;
ORIF
Screws and k wires
Dorsal Plating
Arthrodesis

APPROACH
Dorsal approach

POST OP CARE
Splint 10 14 days,
Short leg cast NWB 4 6 weeks
Short leg cast WB 4 6 weeks
Arch support for 3 6 months
Complications.
Early complications Prognosis;
Vascular injuries. Long rehabilitation (> 1 year)
Foot compartment Incomplete reduction leads to
syndrome. increased incidence of
deformity and chronic foot
Infections and wound pain
complications
Late Complications
Post traumatic Arthritis
Neuromas
Joint Sparing Fixation
Joint sparing fixation techniques including suture
button constructs and dorsal spanning plates have
been explored as alternatives to trans articular screw
fixation due to high rate of post traumatic arthritis .

However suture button may not adequately control

multi instability patron. In these situation standard
techniques or hybrid constructs with both flexible and
rigid fixation are advisable.
 ORIF v/s Arthrodesis
Perhaps the most relevant controversy in the
management of TMT joint is whether to proceed with
ORIF or with primary arthrodesis.

The arthrodesis group had substantially improved

functional outcomes, high return to pre injury level,
low revision rate and less pain at final follow up.

Further studies are needed to clarify which injury

pattern will benefit from primary arthrodesis.
 Anatomy of Talus
Second largest tarsal bone.
Ossification from one centre
which appear in 6th month of
intrauterine life
60 % is covered with articular
cartilage

PARTS OF TALUS
1. HEAD
2. NECK
3. BODY
4. LATERAL PROCESS
5. POSTERIOR PROCESS
Anatomy of Talus
Talus Articulates
with 4 bones

1.Tibia
2. Fibula
3. Calcaneus
4. Navicular
Fracture Talus
ANATOMICAL CLASSIFICATION OF TALUS FRACTURE :-

1. Talar neck fracture

2. Talar body fracture

3. Talar head fracture

4. Lateral process fracture

5. Posterior process fracture

 Clinical Features
Talus fractures frequently occur in a young, active,
and mobile population
History of high velocity injury present

Clinically :-
Intense pain , unable to move ankle,
Gross edema and ecchymosis usually present
When there is subluxation or dislocation the normal
contours of ankle and hind foot are distorted
Open injury may occur if there is significant
distortment
 Diagnosis
XRAYS

ANTEROPOSTERIOR
VIEWS

ANKLE MORTISE VIEW

LATERAL VIEW

CANALE VIEW
 CT SCAN
give excellent visualization
of the congruity of the
subtalar joint and provide
superior details of
fracture.
MRI
demonstrates
osteonecrosis most
effectively.
Use of titanium screws
have been preferred if AVN
of bone is suspected
Fracture Neck of Talus and
Hawkin,s Classification
HAWKIN,S TYPE I
Undisplaced fracture of
talar neck.
Here medial blood supply is still
assured

HAWKIN,S TYPE II
Displaced fracture of the talar
neck with subtalar dislocation or
subluxation.
The medial blood supply may be
preserved
HAWKIN,S TYPE 3,4
TYPE III
Displaced fracture of the talar
neck with dislocation or
subluxation from both the
tibiotalar and subtalar joints.

All medial blood supply to the

body is disrupted
TYPE IV
Displaced fracture of the
talar neck with dislocation or
subluxation of the
talonavicular , tibiotalar , and
subtalar joints.
Worst prognosis because of
AVN of the body and often of
the head fragment
GOALS OF TREATMENT AND
SURGICAL APPROACHES
1. Early anatomic reduction APPROACHES;
of the neck fracture
Anterolateral approach
2. Reduction of dislocated
joints Anteromedial approach
3. Stable fixation Anteromedial approach
combined with medial
4. Avoid of complications
malleolar osteotomy
 TREATMENT FOR
HAWKIN,S TYPE I
Non operative management

Treated with below knee non

weight bearing cast with ankle in
slight equinus for 1 month.
Cast should be removed and
short leg walking cast is applied
for 2 more months until Clinical
and x-ray signs of healing
appears.

Operative management;
Percutaneous screw
TREATMENT FOR HAWKIN,S TYPE II
NON OPERATIVE OPERATIVE
Achieving closed
reduction is very Open reduction internal
difficult. fixation with screws
Should be only
attempted if surgery is
delayed.
TREATMENT FOR HAWKIN,STYPE
III,IV.
Most authors agree that
group III and IV cannot be
reduced and held by closed
attempts
Almost all require surgical
stabilization.

SCREW FIXATION
ANTERIOR TO POSTEROR
POSTERIOR TO ANTERIOR

DIRECT PLATE FIXATION

EXERNAL FIXATION AND
COMPLICATIONS
External Fixation COMPLICATIONS
Limited roles:
Multiply injured AVN
patient with talar neck Malunion
fracture in whom Nonunion
definitive surgery will
Arthritis
be delayed.
Temporary measure to
stabilize reduced joints
REST OF TALUS FRACTURES
Talar body fracture
READ FROM
Talar head fracture TEXT BOOK

Lateral process fracture

Posterior process fracture

Introduction
Approximately 2% of all fractures.
Challenging fracture for orthopedists
90% occur in males between 21-45 years of age.
Although not all these fractures have bad results, the
results of treatment of calcaneus fractures over the years
have not been good.
Anatomy;
Largest Tarsal bone
Ant half-articular surface
Post half-tuberosity

Articular surface for

cuboid
Articular surfaces for talus
Posterior articular facet
Interosseus ligament
Sustentaculum tali
Sinus Tarsi
Classification
Intra-articular fractures 60-75%

Extra-articular fractures 25-30% and include :

1. Anterior process fractures.
2. Beak or avulsion fractures of the tuberosity.
3. Medial process fractures.
4. Sustentaculum tali and body fractures.
Extra Articular Fractures.
Anterior Process Fractures
Inversion sprain
Frequently missed
Most are small: treat like
sprain
Large/displaced: ORIF

Tuberosity Fractures
Fall/MVA Usually non-
operative
Swelling control
Early ROM
PWB
 Tuberosity avulsion
Fractures
Achilles avulsion
Wound problems
Surgical urgency
Lag screws or tension band

Sustentaculum tali
fractures.
May alter ST jt. mechanics
Most small/ non displaced:
Non-operative
Large/ displaced
ORIF (med. approach)
Buttress plate
Intra articular Fractures and their
mechanism
High energy: Axial load
MVA, fall
Lateral process of talus
acts as wedge

Oblique shear
1ry # line 2 fragments:
-- Superomedial (constant)
fragment.
-- Superolateral
fragment>(intra-articular
aspect through post facet)
Intra articular fracture mechanism
Secondary fracture line
runs in one of two
planes
beneath the facet
exiting posteriorly
in tongue-type fracture
behind the posterior
facet in joint
depression fractures
Imaging
Standard Views
1. Lateral
2. Brodens
3. Axial

Scan other regions

- Lumbar spine?
- Contra lateral side?
- Knees?

BRODEN,S VIEW
Positioning
20 IR view (mortise)
10-40 plantar flex

Demonstrating the articular surface of

the posterior facet.
 Lateral view
Bohlers angle Gissanes angle
20-40 95-105
Axial Harris View
Very difficult to obtain in
the acute setting
45 axial of heel
2nd toe in line w/ tibia
Assess varus/valgus
-- Normal 10 valgus --
Joint displacement
Tuberosity angulation
Heel width.
CT imaging in three planes.
30o semi-coronal
ST joint
Heel width/ shortening
Lateral wall blowout
Peroneal impingement
dislocation
Classifications
Essex-Leprosseti
Sanders:
Based on CT findings
Coronal plane
# joint fragments
2 = type II
3 = type III
4 or more = type IV
Predictive of results
Management
Conservative
Operative.
Formal ORIF
Minimally invasive techniques
Ex. Fixation.
Arthrodesis

Approaches.
Medial approaches, lateral
approaches, or dual
approaches
Complications
Post op Complications

Elevate, splint Varus hindfoot

Sutures out @ 3 wks. Shortened foot =
short lever arm
Fracture boot
Peroneal
Early motion impingement/
NWB for 8-12 weeks dislocation
Imp movement up to 2 Shoe wear problems
yrs Valgus>varus with
surgical
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