2. Foot and its bones divided into following three
● Hindfoot-calcaneus and talus
● Midfoot-cuboid,navicular and cuneiforms
● Forefoot-metatarsals and phalanges
5. CALCANEUS FRACTURE
EPIDEMIOLOGY
● CALCANEUS FRACTURE ACCOUNTS FOR
APPROXIMATELY 1% TO 2% OF ALL FRACTURES
● MOST FREQUENTLY FRACTURED TARSAL BONE
● ANNUAL INCIDENCE -11.5 PER 100000 PEOPLE
● M:F IS 2.4:1
● PEAK INCIDENCE IN MALES AGED 20 TO 29 YS
● Rare in childrens(less than 2%) involving older children and
adolescents(>9yr)
● In childrens most are extra-articular, involving the apophysis or
tuberosity
6. Anatomy
● anatomy of calcaneus is complex
● The articular surface contains 3 facets that
articulate with the talus
● The posterior facet is the largest and
constitutes the major weight bearing
surface.
● The middle facet is located anteromedially
on the sustentaculum tali.
7. • B/W the middle and
Posterior facets lies the
interosseoussulcus which,with the
talar sulcus forms the sinus tarsi
• The sustentaculum tali supports
the neck of talus medially, it is
attached to the talus by the
interosseous talocalcaneal ligament
and deltoid ligaments and contains
the middle articular facet on its
superior aspect
8.
9. Radiographic evaluation
● Lateral view of hindfoot
● AP view
● Harris axial view; this is taken with the foot in
dorsiflexion and the beam angled at 45 degrees
● Mortise view
● CT scan
10. The Bohler angle: It is
composed of a line drawn from
the highest point of the anterior
process of calcaneus to the
highest point of posterior facet.
Normally angle is 20 to 40
degrees;decrease in angle
indicates calcaneus fracture
11. The Gissane
angle:Formed by two
strong cortical struts
extending laterally,one along
the lateral margin of the
posterior facet and other
extending anterior to the
beak of the calcaneus:angle
between 105 to 135 degree
12.
13.
14. MECHANISM OF INJURY
Axial loading: -
● falls from a height
● Motor vehicle accidents
Twistingforces
● Associated with extra articular calcaneus
fracture
15. CLASSIFICATION FOR CALCANEUS
FRACTURES
Calcaneus fractures are extra articular fractures and intra articular
fracture
EXTRA ARTICULAR FRACTURES:
These do not involve the posterior facet, these are
● Anterior process fractures
● Medial process fractures
● Sustentacular fractures
● Body fractures not involving the subtalar articulation
● Tuberosity fractures of the posterior calcaneus
16. INTRA ARTICULAR FRACTURES
CLASSIFICATION
Essex-Lopresti classification
Primary Fracture Line:
● force of talus splits the calcaneus obliquely through
the posterior facet
● Anteromedial fragment is rarely comminuted and
remains attached to talus by the deltoid and
interosseous talocalcaneal ligaments
● The posterolateral fragment usually displaces
superolaterally with variable comminution
17. Secondary Fracture Line:
With continued compressive forces,there is
additional comminution ,creating a free lateral
piece of posterior facet separate from the
tuberosity fragment
● Tongue-type fracture:
A secondary fracture line appears beneath the
posterior facet and exits posteriorly through the
tuberosity.
● Joint depression fracture: a secondary fracture
line exits just behind the posterior facet
18.
19. Sanders Classification
● This is based on CT scan
● This classification is based on the number and
location of articular fragments, it is based on the
coronal image which shows the widest surface of
posterior facet of the talus
● The posterior facet of the calcaneus is divided into
3 fracture lines.
● (A, B , AND C corresponding to lateral , middle, d
medial fracture lines on the coronal image)
20. Thus there can be a 4 potential pieces:
lateral,central,medial and sustentaculum tali
● Type 1; all nondisplaced fractures regardless
of the number of fracture lines
● Type 2: two part fractures of the posterior facet
; subtypes 2A,2B,2C, based on the location of
the primary fracture line
● Type 3: 3 parts fractures with a centrally
depressed fragment; subtypes 3AB,3AC,3BC
● Type 4: 4 part articular fractures: highly
comminuted
23. Management
Nonoperative Indications:
● Nondisplaced r minimally displaced extra-
articular fractures
● Nondisplaced intra-articular fractures
● Anterior process fractures with less 25%
involvement of the CC articulation
● Pvd, dm and massive prolong edema
● Other medical comarbidities
24. Nonoperative Treatment
• Consists of a supportive splint to allow
dissipation of the initial fracture hematoma .
• Ankle joint range of motion exercises are initiated
and non weight bearing restrictions are
maintained for 10 to 12 wks.
25. Operative Treatment
Indications:
● Displaced intra-articular fractures involving the posterior facet
● Anterior process of the calcaneus fractures with >25%
involvement of the calcaneal-cuboid articulation
● Open fracture of calcaneus
● Fracture-dislocation of the calcaneus
● Gastrocnemius-soleus complex is incompetent
26.
27.
28. ● Percutaneous or Minimally
Invasive Fixation of Displaced
TongueType, Calcaneal
Tuberosity, or Beak Fractures
● Open Reduction and Internal
Fixation of Anterior Process
Fractures
● Posterior facet reduced and
stabilized with lag screws into
sustentaculum tali. Thin plate
placed laterally and is used as a
buttress.
29. POSTOP MANAGEMENT
● Close clinical follow-up is necessary to ensure soft tissues remain in good condition.
The leg is kept elevated and iced as needed.
● patient can be placed in a well-padded short leg cast with the foot and ankle in slight
plantarflexion.6 weeks,show minimal fracture displacement with acceptable
alignment, the
● patient can be transitioned to a CAM boot with or without a heel lift and can begin
gentle ROM ankle exercises.
30. Complications
● Hardware prominence and pain
● Posttraumatic subtalar arthritis, CC arthritis
● Wound dehiscence, superficial and deep infection, osteomyelitis
● Calcaneal malunion
● Sural nerve injury, painful neuroma
32. ANATOMY
Medially and laterally, the articular cartilage extends plantar to
articulate with the medial and Lateral malleoli, respectively,
The inferior surface of the body forms the articulation with the
posterior facet of the calcaneus
The vascular supply to the talus consists of:
■ Arteries to the sinus tarsi (peroneal and dorsalis pedis arteries)
■ An artery of the tarsal canal (posterior tibial artery)
■ The deltoid artery (posterior tibial artery), which supplies the medial
body
■ Capsular and ligamentous vessels and intraosseous anastomoses
33.
34. EPIDEMIOLOGY
These are second in frequency among all tarsal fractures.
■ The incidence of fractures of the talus ranges from 0.1% to 0.85% of all
fractures and 5% to 7% of foot injuries.
■ Approximately 14% to 26% of talar neck fractures have associated fracture of
the medial malleolus.
■ Lateral process of the talus fractures are frequently seen in snowboarding
injuries and account for 15% of all ankle injuries.
■ Fractures of the talar head are rare with an incidence of 3% to 5% of all
fractures of the talus
35. MECHANISM OF INJURY
● A motor vehicle accidents
● A fall from a height with a component of hyperdorsiflexion of the ankle.
● The talar neck fractures as it impacts the anterior margin of the tibia
● Aviator’s Astragalus: This historical term refers to the rudder bar of a
crashing airplane impacting the plantar aspect of the foot, resulting in a talar neck
fracture.
37. RADIOGRAPHIC EVALUATION
● Ap,lateral and oblique views
■ Canale view: This provides an
optimum view of the talar neck. Taken
with the ankle in maximum equinus, the
foot is placed on a cassette, pronated
15 degrees, and the radiographic
source is directed cephalad 15 degrees
from the vertical . This view was
described for evaluation of
posttraumatic deformity.
CT ,MRI and technetium bone scan
39. TYPE 1: Nondisplaced
TYPE 2:Associated subtalar subluxation or dislocation
TYPE 3:Associated subtalar and ankle dislocation
TYPE 4:Type 3 plus associated talonavicular subluxation or
dislocation
HAWKINS CLASSIFICATION OF TALAR NECK
FRACTURES
40. TREATMENT
Nondisplaced Fracture (Hawkins Type 1)
• Short leg cast or boot for 8 to 12 weeks
• Non weight bearing for 6 weeks until clinical and radiographic
evidence of fracture healing is present
Displaced Fractures (Hawkins Types 2 to 4)
• Immediate closed reduction indicated
• Early ORIF is indicated for all open or irredicible fractures
• If anatomic reduction is obtained and confirmed by CT scan,the pt
can be placed in a short leg splint and fractures fixation may be
delayed
INTERNAL FIXATION: Two interfragmentary lag screws or
headless screws may be placed perpendicular to the fracture line
41. ● Areas of significant comminuation and bone loss should be
grafted
● Mini fragment plates have been used laterally more recently in
cases of significant comminuation to avoid shortening of the
neck
● A short leg cast or removable boot should be placed
postoperatively for 8 to 12 wks and pt should be kept in non
weight bearing
● Nondisplaced or minimally displaced talar body fractures are
treated by shortleg cast
Displaced talar body fractures treated by ORIF
● Less than 2cm displaced lateral process fractures treated by
shortleg cast for 6 wks and be non weight bearing for 4 wks
42. ● More than 2cm displaced fractures treaten by ORIF with lag
screws
● Comminuted fractures: Nonreconstructable fragments are excised
● Nondisplaced or minimally displaced posterior process fractures
managed by shortleg cast for 6wks n non wt bearing for 4wks
● Displaced posterior process fractures managed by ORIF
43. COMPLICATIONS
● Osteonecrosis
● Posttramatic arthritis
● Delayed union and nonunion
● Infections
● Malunion
● Skin slough
● Interposition of long flexor tendons
● Foot compartment syndrome
44. SUBTALAR JOINT DISLOCATION
• It most commonly occurs in young men
• Inversion of the foot results in a medial
subtalar dislocation,whereas evesion
produces a lateral subtalar dislocation
• Up to 85% of dislocations are medial
• All subtalar dislocations require gentle
reduction
• Reduction involves suffiecient analgesia
with knee flexion and longitudinal foot
traction
• Open reduction performed through a
longitudinal anteromedial approach for
medial dislocation and sustentaculum tali
approach for lateral dislocations
46. Epidemiology
● Midfoot injuries relatively rare
● Incidence of midfoot fractures is 3.6 per
1,00,000 per yr
● Cuboid is most commonly fractured bone
followed by navicular and cuneiform
● Male:female=1:1.2
47. Anatomy
● The midfoot is the section of the foot distal to chopart joint line and
proximal to lisfranc joint line
● Five bones constitute in midfoot. Navicular,cuboid and 3
cuneiforms
● The midtarsal joint consists of the calcaneocuboid and
talonavicular joints, which act in concert with subtalar joint during
inversion and eversion of the foot
● Ligamentous attachments include the plantar calcaneonavicular
ligament,bifurcate ligament,dorsal talonavicular ligament,dorsal
calcaneocuboid ligament,dorsal cuboideonavicular ligament and
long plantar ligament
48.
49. MOI
High Energy Trauma - motor vehicle accidents
- Fall or jump from a height
Low Energy Trauma - sprain during athletic or dance
activities
C/f:Swelling and tenderness on the dorsum of the midfoot to
nonambulatory status with significant pain, gross
swelling,ecchymosis, and variable deformity
Plantar ecchymosis is usually indicative of midfoot injury
50. Radiographic Evaluation
● AP,Lateral and oblique views foot should be
obtained
● CT helpful in fracture dislocation injuries with
articular comminution
● MRI for ligamentous injuries
51. CLASSIFICATION OF MIDFOOT INJURIES
Medial stress injury:
● Inversion injury occurs with adduction of the
midfoot on the hindfoot.
● Flake fractures of the dorsal margin of the
talus or navicular and of the lateral margin of
the calcaneus or the cuboid may indicate a
sprain
53. Lateral stress injury
● Nutcracker fracture; this is the fracture of
the cuboid as the forefoot driven laterally,
crushing the cuboid between the
calcaneus and the 4th and 5th metatarsal
bases
● Most commonly this is an avulsion
fracture of the navicular with a
comminuted compression fracture of the
cuboid
54. Plantar stress injury:
Forces directed at the plantar region may
result in sprains to the midtarsal fractures of
the navicular,talus, or anterior process of
the calcaneus
55. TREATMENT
Nonoperative:
● Sprains: nonrigid dressings are used with protected
weight bearing for 4 to 6 wks ,prognosis is excellent
● For severe sprains , midfoot immobilization may be
indicated
● Nondisplaced fractures may be treated with a short
leg cast or brase with initial non weight bearing for
6 wks
56.
57. Operative
● Displaced fracture patterns require
ORIF(K-WIRES) and external fixation
● Bone grafting of the cuboid may be
necessary following reduction of lateral
stress injuries
● Severe crush injuries with extensive
comminution may require arthrodesis
to restore the longitudinal arch of the
foot
58. Navicular Bone Anatomy
Navicular is the keystone of the
medial longitudinal arch of the foot.
■ It is wider on its dorsal and
medial aspect than on its plantar
and lateral aspect.
■ The medial prominence known
as the navicular tuberosity provides
the attachment point for the
posterior tibialis on its medial
inferior surface.
59. Sangeorzan Classification of Navicular Bone
• The most commonly used classification of navicular fractures is
composed of three basic types with a subclassification for body
fractures
• Avulsion-type fracture can involve either the talonavicular or
naviculocuneiform ligaments.
• Tuberosity fractures are usually traction-type injuries with
disruption of the tibialis posterior insertion without joint surface
disruption.
• Type I body fracture splits the navicular into dorsal and plantar
segments.
• Type II body fractures cleave into medial and lateral segments.
The location of the split usually follows either of the two
intercuneiform joint lines. Stress fractures can usually be
included in this group.
• Type III body fractures are distinguished by comminution of the
fragments and significant displacement of the medial and lateral
poles.
60. Treatment For Navicular Bone Fracture
Nonoperative
● Nondisplaced fractures of the navicular should
be treated in a short leg cast or fracture brace
with restricted weight bearing for 6 to 8 weeks.
● Repeat radiographs should be obtained at 10
to 14 days after the initial injury to confirm the
absence of bony or soft tissue instability. If
instability appears or other injuries become
apparent, appropriate surgical intervention
should be considered.
Operative
● K wire fixation
● Bone graft
Postop management:
Cast with non weight bearing for 12wks
61. LISFRANC INJURY(TARSOMETATARSAL JOINT INJURY)
● Rare, mostly seen in poly-traumatized pt’s.
● MOI :3 most common mechanism include
1. Torsion: seen in motor vehicle accidents and horse rider
2. Axial loading: seen in jumping and dancing
3. Crushing mechanism: industrial type injuries
C/F:
● Pain
● Swelling
● Tenderness
● Plantar ecchymosis is pathognomonic feature for lisfranc injury
62. Radiographic Evaluation
• AP, LATERAL AND OBLIQUE FIMLS ARE DIAGNOSTIC
• THE MEDEAL BORDER OF THE 2ND METATARSALSHOULD BE
COLINEAR WITH THE MEDIAL BORDER OF THE MIDDLE CUNEIFORM ON
THE AP VIEW
63. • The medial border of the 4th metatarsal should be colinear with the
medial border of the cuboid on oblique view
• Dorsal displacement of the metatarsals on the lateral view is
indicative of ligamentous compromise
• MRI and CT scan also useful for suspected lisfranc injuries
64. QUENU AND KUSS Classification of lisfranc injuries
Based on extent and pattern of injury
● Homolateral: all five metatarsals displaced in the same
direction
● Isolated: one or two metatarsals displaced from the others
● Divergent: displacement of the metatarsals in both the sagittal
and coronal planes
65. MYERSON CLASSIFICATION
Commonly observed patterns of injury
with regard to treatment
● Total incongruity:lateral and
dorsoplantar
● Partial incongruity:medial and
lateral
● Divergent:partial and total
66. Treatment
Nonoperative
● Short leg cast for pt with nondisplaced ligamentous
injuries with or without small Plantar avulsion fractures of
the metatarsal or tarsal bones
● Pt kept non weight bearing to bear weight as comfort
allows with crutches and is permitted
67. Operative
● This should be considered when
displacement of the tarsometatarsal
joint is >2mm
● The most common approach is using
two longitudinal incisions
● First one is centered over the first
/second inermetatarsal space
● 2nd one at 4th metatarsal
● Once reductionis accomplished, screw
fixation is advocated for the medial
column
● K wire fixation is acceptable
68. Postoperative management:
● The foot is immobilized in a non weight bearing
cast or boot for 6 to 8wks
● Lateral column stabilization can be removed at
6 to 12 wks
● Medial fixation should not be removed for 4 to 6
months
● Some advocate leaving screws indefinitely
unless symptomatic
71. FOREFOOT FRACTURES
The forefoot serves two purposes during gait
● It provides a broad plantar surface for load
sharing
● The forefoot is mobile in the sagittal plane.
This helps to the forefoot to alter the position
of the individual metatarsal heads to
accommodate uneven grounds
73. MOI
● Direct:this is mc when a heavy object is dropped on the
forefoot
● Avulsion
● Stress fracture:improper running usually gives rise to
the more insidious stress fracture
● Torsion
74. C/F:
● Pain
● Swelling and tenderness over the site of
fracture
● Neurovascular evaluation is important as well
as assessment of soft injury
75. RADIOGRAPHIC EVALUATION
● AP,Lateral and oblique views of
the forefoot should be obtained
● Occasionally , a tangential view
of the sesamoids is necessary
to visualize a small
osteochondral or avulsion
fracture
● Technetium bone scanning or
MRI may be used to identify
stress fractures
76. TREATMENT FOR FOREFOOT FRACTURE
Nonoperative:
● Rest,ice,compression and elevation and
nonsteroidal anti-inflammatory medication are
used
● Splinting: soft padding combined with a short
leg walking cast for 4 to 6 wks
● Rigid or stiff-soled shoe
● Buddy taping for phalanges fractures
79. Named Fractures In Foot
Shepherd’s fracture: fracture of the lateral tubercle of
the posterior process of the talus
March fracture:it occurs in distal 3rd of one of the
metatarsals(2nd and 3rd commonly) d/t recurrent stress
80. Chopart`s fracture-dislocation:
Foot dislocation through talonavicular and calcaneocuboid joints
Lisfranc fracture fracture dislocation of midfoot from
tarsometatarsal joints
Jones fracture:distal to tuberosity of the base of 5th
metatarsal fracture(zone2)
Pseudo jones fracture: Cancellous tuberosity
fracture(zone1) of the base of 5th metatarsal
81. Amputation surgeries for foot
• Syme’s amputation
• Choparts amputation
• Lisfranc’s amputation
• Transmetatarsal amputation
• Metatarsal phalangeal disarticulation
• Toe amptation or disarticulation
