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Midfoot Fractures

Midfoot Fractures. Jenny Jefferis. What is a midfoot fracture?. Fracture of the midfoot involving the: Tarsometatarsal joint (Lisfranc Fracture) Cuneiforms Tarsal navicular bone Cuboid bone. What is a Lisfranc Fracture?. Between the tarsal and metatarsal bones

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Midfoot Fractures

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  1. Midfoot Fractures Jenny Jefferis

  2. What is a midfoot fracture? • Fracture of the midfoot involving the: • Tarsometatarsal joint (Lisfranc Fracture) • Cuneiforms • Tarsal navicular bone • Cuboid bone

  3. What is a Lisfranc Fracture? • 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

  4. 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

  5. Various fractures of the tarsal navicular bone include: • Cortical avulsions • Most common • Results from twisting forces on the mid foot • Fracture of the tuberosity • May involve the post. tibial tendon • Bony fractures • Stress fractures

  6. Tarsal Navicular Fracture • Frequently have posttraumatic arthritis & discomfort in all phases of gait • Requires immobilization in a non-weight bearing short leg cast

  7. 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.

  8. Cuneiform Fracture • Uncommon • Usually occur w/ high-energy injuries • Open reduction & internal fixation is recommended

  9. Mechanism of Injury • 3 common causes • Twisting of the forefoot • Often occur during vehicle accidents when the foot is abducted • Axial loading of a fixed foot • Occurs when falling on an extremely dorsiflexed foot or axial loading from body weight, stepping off a curb • Crushing • To the dorsum of the foot • Usually in industrial accidents • Clinician should be aware of compartment syndrome & injury to the dorsal pedis artery

  10. Treatment Goals Alignment- Restoring 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

  11. Treatment Goals • Stability • Stable fixation of the navicular & cuboid • 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

  12. Range of Motion

  13. Muscle Strength Invertors • Tibialis Anterior • Tibialis Posterior • Evertors • Peroneus Longus • Peroneus Brevis • Dorsiflexors • Tibialis Anterior • Toeextensors • 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

  14. Time of Bone Healing • Tarsometatarsal or Lisfranc Fracture • 8-10 weeks • Tarsal Navicular • 6-10 weeks • Cuboid & Cuneiform Fracture • 6-10 weeks

  15. Duration of Rehabilitation • Tarsometatarsal or Lisfranc Fracture • 8 weeks- 4 months • Tarsal Navicular • Acute Fx:6 wks- 4 months • Delayed union, nonunion, or stress fx: 6 wks- 4 months • Cuboid & Cuneiform Fracture • 6 wks- 4 months

  16. Treatment Methods • Tarsometatarsal or Lisfranc Fx: • Cast: • Biomechanics: stress-sharing 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.

  17. Treatment Methods • Open Reduction & Internal Fixation • 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.

  18. Treatment Methods • Closed Reduction & Percutaneous Pinning • Biomechanics: Stress-sharing device w/ pin fixation • Mode of bone healing: Secondary, w/ callus formation • Indications: Kirschner-wire fixation. Placed in a non-weight bearing short leg cast after fixation. Wires removed at 6 wks, followed by protective weight bearing.

  19. Treatment Methods • Tarsal Navicular Fx • Cast • Biomechanics: stress-sharing device • Mode of bone healing: Secondary, w/ callus formation • Indications: May be placed in a short leg cast. • Cortical avulsion fx: short leg walking cast, 4-6 wks. • Tuberosity fx: Short leg walking cast, 4-6 wks.

  20. Treatment Methods • Open Reduction & Internal Fixation • 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

  21. Treatment Methods • Cuboid & Cuneiform Fx • Cast • Biomechanics: Stress-sharing device • Mode of bone healing: Secondary w/ minimum callus formation • Indications: • Cuboids: closed in a weight bearing cast • Cuneiforms: short leg cast, immobilized because of ligamentous damage

  22. Treatment Methods • Open Reduction Internal Fixation • Biomechanics: stress-shielding device • Mode of bone healing: primary, w/ rigid fixation • Indications: • open reduction & internal fixation for any amount of displacement, followed by a 6 wk. period of non-weight bearing.

  23. Special Considerations of the Fx • Age • Joint stiffness particularly w/ navicular fx’s • Active Pts. Also are probe to jt. Stiffness w/ a navicular fx • Articular Involvement • Posttraumatic arthritis & fusion • Limited pronation & supination • Location or possible • Open Fractures • Damage to the dorsal pedis artery • Open fx must undergo irrigation, debridement, & intrevenous antibiotics • Always a possibility of compartment syndrome • Tendon & Ligament Injuries • Extensor tendons should be inspected for possible damage

  24. Gait • Stance Phase • 60% of gait cycle • Heel Strike • ↑ pn from inversion to eversion • Foot-Flat • Painful b/c of injured bones of the medial arch • Mid-Stance • Painful as foot is moving from neutral to eversion • Push-Off • Pt may limit plantar flexion • Cycle is shortened • Swing Phase • 40% of gait cycle • Not affected by any of these fxs b/c foot is not in contact w/ ground

  25. http://www.youtube.com/watch?v=5nokor_ecSI • http://www.youtube.com/watch?v=r8-eG9hc344&feature=related • http://video.aol.com/video-detail/short-leg-cast/4134668378

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