Download Midfoot Fractures

Midfoot Fractures
Jenny Jefferis
What is a midfoot fracture?
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Fracture of the midfoot
involving the:
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Tarsometatarsal joint
(Lisfranc Fracture)
Cuneiforms
Tarsal navicular bone
Cuboid bone
What is a Lisfranc Fracture?
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Between the tarsal and metatarsal bones
The 1st & 2nd metatarsal articulates with
the medial cuneiforms and are the
keystones of the foot
Supplies stability between the midfoot &
forefoot during gait
Lisfranc Fracture

Frontal view of the
foot shows
fracture/
dislocation in the
tarsometatarsal
joint (Lisfranc's
joint) with
dislocations of the
1st through 5th
metatarsals
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Various fractures of the tarsal navicular bone
include:
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Cortical avulsions
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Fracture of the tuberosity
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Most common
Results from twisting forces on the mid foot
May involve the post. tibial tendon
Bony fractures
Stress fractures
Tarsal Navicular Fracture

Frequently have
posttraumatic
arthritis &
discomfort in all
phases of gait

Requires
immobilization in
a non-weight
bearing short leg
cast
Cuboid Fracture

Known as nutcracker
fractures because the
cuboid is cracked like a
nut b/w the 5th metatarsal
& the calcaneous as the
forefoot is forced into
abduction.
Cuneiform Fracture
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Uncommon
Usually occur w/ highenergy injuries
Open reduction &
internal fixation is
recommended
Mechanism of Injury
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3 common causes
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Twisting of the forefoot
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Axial loading of a fixed foot
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Occurs when falling on an extremely dorsiflexed foot or axial
loading from body weight, stepping off a curb
Crushing
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Often occur during vehicle accidents when the foot is abducted
To the dorsum of the foot
Usually in industrial accidents
Clinician should be aware of compartment syndrome &
injury to the dorsal pedis artery
Treatment Goals
AlignmentRestoring the alignment with the cuneiforms
-Important for normal weight bearing
-Load distribution of the foot
-To maintain the medial arch of the foot
Restoring the length & alignment of:
cuneiforms
cuboid
navicular
Treatment Goals
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Stability
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Stable fixation of the navicular & cuboid
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Allows effective transfer of weight from the hind foot
Helps with eversion & inversion of the subtalar jt.
A stable reconstruction of the Lisfranc joint

Important in maintaining the medial arch of the foot & a
pn free and secure gait
Range of Motion
Motion
Normal
Functional
Ankle Plantar
Flexion
Ankle
Dorsiflexion
Foot Inversion
45°
20 °
20-25 °
10 °
35 °
10 °
Foot Eversion
25 °
10 °
Muscle Strength
Invertors
 Tibialis Anterior
 Tibialis Posterior
 Evertors
 Peroneus Longus
 Peroneus Brevis
 Dorsiflexors
 Tibialis Anterior
 Toe extensors
 Plantar Flexors
 Gastrocnemius
 Soleus
 Tibialis Posterior
Peroneous Longus weakness
can result from severe dislocations
of the Lisfranc Fracture because
this muscle inserts on the 1st
metatarsal & 1st cuneiform
Time of Bone Healing
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Tarsometatarsal or Lisfranc Fracture
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Tarsal Navicular
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8-10 weeks
6-10 weeks
Cuboid & Cuneiform Fracture
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6-10 weeks
Duration of Rehabilitation
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Tarsometatarsal or Lisfranc Fracture
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Tarsal Navicular
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8 weeks- 4 months
Acute Fx:6 wks- 4 months
Delayed union, nonunion, or stress fx: 6 wks- 4
months
Cuboid & Cuneiform Fracture
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6 wks- 4 months
Treatment Methods
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Tarsometatarsal or
Lisfranc Fx:
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Cast:
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Biomechanics: stresssharing device
Mode of Bone Healing:
Secondary, with callus
formation
Indications: May be
treated w/ a short leg
cast for 6 wks. May bear
weight when pn free.
Treatment Methods
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Open Reduction & Internal
Fixation
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Biomechanics: stress-shielding
device w/ screw fixation
Mode of healing: Primary, w/
rigid fixation
Indications: Pt placed in a
weight bearing cast for 6 wks.
Unprotected weigh bearing is
not recommended until screws
are removed at least 10-12 wks
after surgery.
Treatment Methods
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Closed Reduction &
Percutaneous Pinning
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Biomechanics: Stresssharing device w/ pin fixation
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Mode of bone healing:
Secondary, w/ callus
formation
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Indications: Kirschner-wire
fixation. Placed in a nonweight bearing short leg cast
after fixation. Wires removed
at 6 wks, followed by
protective weight bearing.
Treatment Methods
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Tarsal Navicular Fx
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Cast
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Biomechanics: stress-sharing device
Mode of bone healing: Secondary, w/ callus formation
Indications: May be placed in a short leg cast.
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Cortical avulsion fx: short leg walking cast, 4-6 wks.
Tuberosity fx: Short leg walking cast, 4-6 wks.
Treatment Methods
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Open Reduction & Internal Fixation
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Biomechanics: Stress-shielding device w/ rigid
fixation
Mode of bone healing: Primary, w/out callus
formation
Indications: To avoid severe deformity & arthritis,
must be treated w/ reduction & rigid fixation
Treatment Methods
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Cuboid & Cuneiform Fx
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Cast
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Biomechanics: Stress-sharing device
Mode of bone healing: Secondary w/
minimum callus formation
Indications:
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Cuboids: closed in a weight bearing cast
Cuneiforms: short leg cast, immobilized
because of ligamentous damage
Treatment Methods
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Open Reduction Internal Fixation
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Biomechanics: stress-shielding device
Mode of bone healing: primary, w/ rigid fixation
Indications:
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open reduction & internal fixation for any amount of
displacement, followed by a 6 wk. period of nonweight bearing.
Special Considerations of the Fx
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Age
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Articular Involvement
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Posttraumatic arthritis & fusion
Limited pronation & supination
Location or possible
Open Fractures
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Joint stiffness particularly w/ navicular fx’s
Active Pts. Also are probe to jt. Stiffness w/ a navicular fx
Damage to the dorsal pedis artery
Open fx must undergo irrigation, debridement, & intrevenous antibiotics
Always a possibility of compartment syndrome
Tendon & Ligament Injuries
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Extensor tendons should be inspected for possible damage
Gait
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Stance Phase
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Heel Strike
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Painful as foot is moving from neutral to eversion
Push-Off
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Painful b/c of injured bones of the medial arch
Mid-Stance
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↑ pn from inversion to eversion
Foot-Flat
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60% of gait cycle
Pt may limit plantar flexion
Cycle is shortened
Swing Phase
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40% of gait cycle
Not affected by any of these fxs b/c foot is not in contact w/ ground
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http://www.youtube.com/watch?v=5nokor_ec
SI
http://www.youtube.com/watch?v=r8eG9hc344&feature=related
http://video.aol.com/video-detail/short-legcast/4134668378